Provider Demographics
NPI:1275954737
Name:WEISS WELLNESS & CHIROPRACTIC, LTD.
Entity Type:Organization
Organization Name:WEISS WELLNESS & CHIROPRACTIC, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEACH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-828-3415
Mailing Address - Street 1:409 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-5309
Mailing Address - Country:US
Mailing Address - Phone:309-828-3415
Mailing Address - Fax:
Practice Address - Street 1:409 E FRONT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-5309
Practice Address - Country:US
Practice Address - Phone:309-828-3415
Practice Address - Fax:309-828-2665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-30
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038005425111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty