Provider Demographics
NPI:1295831402
Name:EDMISTON, RONALD (DC)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:EDMISTON
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 1:103B SOUTH POINTE DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLRE
Mailing Address - State:IL
Mailing Address - Zip Code:62025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:344 S FILLMORE ST
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2115
Practice Address - Country:US
Practice Address - Phone:618-692-6700
Practice Address - Fax:618-692-6711
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor