Provider Demographics
NPI:1265502611
Name:KOMESHAK, GREG S (DC)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:S
Last Name:KOMESHAK
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 1:705 W US HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1900
Mailing Address - Country:US
Mailing Address - Phone:618-624-4242
Mailing Address - Fax:618-624-5127
Practice Address - Street 1:705 W US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1900
Practice Address - Country:US
Practice Address - Phone:618-624-4242
Practice Address - Fax:618-624-5127
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009537111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor