Provider Demographics
NPI:1245384528
Name:WILLIAM L. JUDGE CHIROPRACTIC CENTER, PC
Entity Type:Organization
Organization Name:WILLIAM L. JUDGE CHIROPRACTIC CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC, OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:JUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-223-0647
Mailing Address - Street 1:130 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-2312
Mailing Address - Country:US
Mailing Address - Phone:815-223-0647
Mailing Address - Fax:815-223-0987
Practice Address - Street 1:130 3RD ST
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301-2312
Practice Address - Country:US
Practice Address - Phone:815-223-0647
Practice Address - Fax:815-223-0987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-004603111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038004603Medicaid