Provider Demographics
NPI:1376620260
Name:SOUTHERN ILLINOIS CHIROPRACTIC KINESIOLOGYPC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS CHIROPRACTIC KINESIOLOGYPC
Other - Org Name:OSBORNE FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DIBAK, DCBCN, DC
Authorized Official - Phone:618-622-9780
Mailing Address - Street 1:4965 STONE FALLS CENTER
Mailing Address - Street 2:SUITE 7
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7803
Mailing Address - Country:US
Mailing Address - Phone:618-622-9780
Mailing Address - Fax:618-622-9782
Practice Address - Street 1:4965 STONE FALLS CENTER
Practice Address - Street 2:SUITE 7
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-7803
Practice Address - Country:US
Practice Address - Phone:618-622-9780
Practice Address - Fax:618-622-9782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009255111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03227051OtherPROVIDER #
IL462042OtherPROVIDER #
IL462042OtherPROVIDER #
IL1124040688Medicare UPIN
IL211614Medicare ID - Type UnspecifiedGROUP