Provider Demographics
NPI:1194040121
Name:CENTRAL STATE CHIROPRACTIC & REHABILITATION
Entity Type:Organization
Organization Name:CENTRAL STATE CHIROPRACTIC & REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:BURNETT
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-398-2225
Mailing Address - Street 1:2101 WINDSOR PL
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7769
Mailing Address - Country:US
Mailing Address - Phone:217-398-2225
Mailing Address - Fax:217-398-2224
Practice Address - Street 1:2101 WINDSOR PL
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7769
Practice Address - Country:US
Practice Address - Phone:217-398-2225
Practice Address - Fax:217-398-2224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.008791111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01022961OtherBLUE CROSS / BLUE SHIELD
561100Medicare UPIN