Provider Demographics
NPI:1407452345
Name:JERSEYVILLE CHIROPRACTIC AND REHAB LLC
Entity Type:Organization
Organization Name:JERSEYVILLE CHIROPRACTIC AND REHAB LLC
Other - Org Name:WILLIAMS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RACE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-345-8400
Mailing Address - Street 1:223 SALT LICK RD # 280
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-5974
Mailing Address - Country:US
Mailing Address - Phone:636-345-8400
Mailing Address - Fax:
Practice Address - Street 1:519 S STATE ST
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2241
Practice Address - Country:US
Practice Address - Phone:618-639-6611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-07
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty