Provider Demographics
NPI:1346348802
Name:WALTON CS-XVI PC
Entity Type:Organization
Organization Name:WALTON CS-XVI PC
Other - Org Name:PRIMARY CARE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:CARLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-263-5698
Mailing Address - Street 1:831 W JACKSON PLAZA
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-1569
Mailing Address - Country:US
Mailing Address - Phone:309-263-5698
Mailing Address - Fax:309-263-5698
Practice Address - Street 1:831 W JACKSON PLAZA
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-1569
Practice Address - Country:US
Practice Address - Phone:309-263-5698
Practice Address - Fax:309-263-5697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.012090111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211259Medicare ID - Type UnspecifiedGROUP NUMBER