Provider Demographics
NPI:1275658908
Name:CLOE, KEITH ALAN (DC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALAN
Last Name:CLOE
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 1:330 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-5116
Mailing Address - Country:US
Mailing Address - Phone:618-241-9211
Mailing Address - Fax:618-241-9212
Practice Address - Street 1:330 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-5116
Practice Address - Country:US
Practice Address - Phone:618-241-9211
Practice Address - Fax:618-241-9212
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008422111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4122210OtherBLUE CROSS BLUE SHIELD
IL038008422Medicaid
IL4122210OtherBLUE CROSS BLUE SHIELD