Provider Demographics
NPI:1114139904
Name:PRIDE CLINIC, SC
Entity Type:Organization
Organization Name:PRIDE CLINIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:PRIDE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-352-9108
Mailing Address - Street 1:3105 VILLAGE OFFICE PLACE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822
Mailing Address - Country:US
Mailing Address - Phone:217-352-9108
Mailing Address - Fax:
Practice Address - Street 1:3105 VILLAGE OFFICE PLACE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822
Practice Address - Country:US
Practice Address - Phone:217-352-9108
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38684Medicare UPIN