Provider Demographics
NPI:1407043714
Name:FRYE FUNCTIONAL HEALTH CENTER
Entity Type:Organization
Organization Name:FRYE FUNCTIONAL HEALTH CENTER
Other - Org Name:FRYE CHIROPRACTIC & LASER CENTER, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:N
Authorized Official - Last Name:FRYE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-692-1800
Mailing Address - Street 1:3809 S STATE ROUTE 159
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-3020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3809 S STATE ROUTE 159
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-3020
Practice Address - Country:US
Practice Address - Phone:618-692-1800
Practice Address - Fax:618-205-8664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38011010111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty