Provider Demographics
NPI:1275703712
Name:LITCHFIELD PHYSICAL MEDICINE, LTD
Entity Type:Organization
Organization Name:LITCHFIELD PHYSICAL MEDICINE, LTD
Other - Org Name:MILTON CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-465-8200
Mailing Address - Street 1:3464 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-2043
Mailing Address - Country:US
Mailing Address - Phone:618-465-8200
Mailing Address - Fax:618-465-8184
Practice Address - Street 1:3464 E BROADWAY
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-2043
Practice Address - Country:US
Practice Address - Phone:618-465-8200
Practice Address - Fax:618-465-8184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009755111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038009755Medicaid
IL209986Medicare PIN