Provider Demographics
NPI:1093939613
Name:DISHONG CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:DISHONG CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERALD
Authorized Official - Middle Name:ORVILLE
Authorized Official - Last Name:DISHONG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-392-2223
Mailing Address - Street 1:600 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-1542
Mailing Address - Country:US
Mailing Address - Phone:618-392-2223
Mailing Address - Fax:618-392-3261
Practice Address - Street 1:600 W MAIN ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-1542
Practice Address - Country:US
Practice Address - Phone:618-392-2223
Practice Address - Fax:618-392-3261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08020396OtherBLUE CROSS BLUE SHIELD
IL233510Medicare ID - Type Unspecified
IL08020396OtherBLUE CROSS BLUE SHIELD