Provider Demographics
NPI:1194027003
Name:SCHELLY CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:SCHELLY CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-682-6624
Mailing Address - Street 1:1208 W LOUCKS AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-2604
Mailing Address - Country:US
Mailing Address - Phone:309-682-6624
Mailing Address - Fax:309-682-6625
Practice Address - Street 1:1208 W LOUCKS
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604
Practice Address - Country:US
Practice Address - Phone:309-682-6624
Practice Address - Fax:309-682-6625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38006410111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4971Medicare UPIN
ILIL4971Medicare PIN