Provider Demographics
NPI:1275524241
Name:GALENA CHIROPRACTIC CENTER PC
Entity Type:Organization
Organization Name:GALENA CHIROPRACTIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:NEWCOMER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-777-0042
Mailing Address - Street 1:400 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:IL
Mailing Address - Zip Code:61036-1902
Mailing Address - Country:US
Mailing Address - Phone:815-777-0042
Mailing Address - Fax:815-777-0043
Practice Address - Street 1:400 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:IL
Practice Address - Zip Code:61036-1902
Practice Address - Country:US
Practice Address - Phone:815-777-0042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL644160Medicare ID - Type Unspecified
T37429Medicare UPIN