Provider Demographics
NPI:1114057312
Name:HOLISTIC CHIROPRACTIC & REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:HOLISTIC CHIROPRACTIC & REHABILITATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:F
Authorized Official - Last Name:LAHUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-624-9384
Mailing Address - Street 1:4965 STONE FALLS CTR
Mailing Address - Street 2:SUITE 7
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7802
Mailing Address - Country:US
Mailing Address - Phone:618-624-9384
Mailing Address - Fax:618-624-9386
Practice Address - Street 1:4965 STONE FALLS CTR
Practice Address - Street 2:SUITE 7
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-7802
Practice Address - Country:US
Practice Address - Phone:618-624-9384
Practice Address - Fax:618-624-9386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X, 111N00000X, 111N00000X, 111N00000X, 111NN1001X, 111NN1001X, 111NN1001X, 111NN1001X, 111NR0400X, 111NR0400X, 111NR0400X, 111NR0400X, 2251E1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
Not Answered111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
Not Answered2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, ClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08232126OtherIL BCBS GROUP NUMBER
IL690962OtherHEALTHLINK GROUP NUMBER
IL210573Medicare ID - Type UnspecifiedIL MCR GROUP NUMBER