Provider Demographics
NPI:1225001506
Name:VANNATTA, MICHAEL J (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:VANNATTA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2514 24TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5304
Mailing Address - Country:US
Mailing Address - Phone:309-786-2200
Mailing Address - Fax:309-788-3638
Practice Address - Street 1:2514 24TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5304
Practice Address - Country:US
Practice Address - Phone:309-786-2200
Practice Address - Fax:309-788-3638
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038005397111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0008182068OtherBLUE CROSS/BLUE SHIELD
IA0994608Medicaid
651035OtherUNITED HEALTHCARE
239923OtherMIDLAND CHOICE
IA90782OtherBLUE CROSS/BLUE SHIELD
IL038005397Medicaid
239923OtherMIDLAND CHOICE
IL988900Medicare ID - Type Unspecified