Provider Demographics
NPI:1144408774
Name:PREMIER CHIROPRACTIC ROCKFORD
Entity Type:Organization
Organization Name:PREMIER CHIROPRACTIC ROCKFORD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GABRYSHAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-227-9949
Mailing Address - Street 1:123 N ALPINE RD
Mailing Address - Street 2:A
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-4980
Mailing Address - Country:US
Mailing Address - Phone:815-227-9949
Mailing Address - Fax:
Practice Address - Street 1:123 N ALPINE RD
Practice Address - Street 2:A
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-4980
Practice Address - Country:US
Practice Address - Phone:815-227-9949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211581Medicare PIN
ILK22592Medicare UPIN