Provider Demographics
NPI:1356637938
Name:GRIESBAUM FAMILY CHIROPRACTIC S C
Entity Type:Organization
Organization Name:GRIESBAUM FAMILY CHIROPRACTIC S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GRIESBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-268-9888
Mailing Address - Street 1:1607 VISA DR
Mailing Address - Street 2:1A
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2137
Mailing Address - Country:US
Mailing Address - Phone:309-268-9888
Mailing Address - Fax:309-268-9887
Practice Address - Street 1:1607 VISA DR
Practice Address - Street 2:1A
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2137
Practice Address - Country:US
Practice Address - Phone:309-268-9888
Practice Address - Fax:309-268-9887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-22
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008016111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL350046480OtherRAILROAD MEDICARE
IL05722922OtherBLUE CROSS BLUE SHIELD
ILU68254Medicare UPIN