Provider Demographics
NPI:1245412998
Name:VILLAGE CHIROPRACTIC
Entity Type:Organization
Organization Name:VILLAGE CHIROPRACTIC
Other - Org Name:BACK IN SHAPE CHIROPRACTIC AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:B
Authorized Official - Last Name:POTETTI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-398-3334
Mailing Address - Street 1:1639 N ALPINE RD
Mailing Address - Street 2:503
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1449
Mailing Address - Country:US
Mailing Address - Phone:815-398-3334
Mailing Address - Fax:815-398-3469
Practice Address - Street 1:1639 N ALPINE RD
Practice Address - Street 2:503
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1449
Practice Address - Country:US
Practice Address - Phone:815-398-3334
Practice Address - Fax:815-398-3469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care