Provider Demographics
NPI:1225039324
Name:KRUCKENBERG, GERALDINE MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:GERALDINE
Middle Name:MARIE
Last Name:KRUCKENBERG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:GERALDINE
Other - Middle Name:MARIE
Other - Last Name:GADOMSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1715 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-7911
Mailing Address - Country:US
Mailing Address - Phone:309-764-9255
Mailing Address - Fax:309-762-1064
Practice Address - Street 1:1715 5TH AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-7911
Practice Address - Country:US
Practice Address - Phone:309-764-9255
Practice Address - Fax:309-762-1064
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038 007464111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
08132048OtherBCBS
1179978OtherIA PUBLIC AID
IL038 007464Medicaid
ILP00174127OtherMEDICARE RAILROAD
1179978OtherIA PUBLIC AID
08132048OtherBCBS