Provider Demographics
NPI:1215010673
Name:PRIDEMORE CHIROPRACTIC CENTER, INC
Entity Type:Organization
Organization Name:PRIDEMORE CHIROPRACTIC CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JEFFERSON
Authorized Official - Last Name:PRIDEMORE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:309-837-6555
Mailing Address - Street 1:PO BOX 893
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-0893
Mailing Address - Country:US
Mailing Address - Phone:309-837-6555
Mailing Address - Fax:
Practice Address - Street 1:112 N SCOTLAND ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-2535
Practice Address - Country:US
Practice Address - Phone:309-837-6555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-21
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
038009915111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK02962Medicare PIN