Provider Demographics
NPI:1154839777
Name:MCCONNELL, OWEN JAMES (DC, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:OWEN
Middle Name:JAMES
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:DC, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:IL
Mailing Address - Zip Code:61250-9665
Mailing Address - Country:US
Mailing Address - Phone:309-737-9554
Mailing Address - Fax:
Practice Address - Street 1:810 S CHICAGO ST
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1804
Practice Address - Country:US
Practice Address - Phone:309-737-9554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL038.013797111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program