Provider Demographics
NPI:1245423748
Name:BLY CHIROPRACTIC CLINIC, P.C.
Entity Type:Organization
Organization Name:BLY CHIROPRACTIC CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-661-1155
Mailing Address - Street 1:2501 E COLLEGE AVE
Mailing Address - Street 2:STE C
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2484
Mailing Address - Country:US
Mailing Address - Phone:309-661-1155
Mailing Address - Fax:309-661-1043
Practice Address - Street 1:2501 E COLLEGE AVE
Practice Address - Street 2:STE C
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2484
Practice Address - Country:US
Practice Address - Phone:309-661-1155
Practice Address - Fax:309-661-1043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05715393OtherBLUE CROSS BLUE SHIELD
IL05715393OtherBLUE CROSS BLUE SHIELD