Provider Demographics
NPI:1407991771
Name:SOUTHERN ILLINOIS CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:T
Authorized Official - Last Name:DELASSUS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-288-7991
Mailing Address - Street 1:2 PROFESSIONAL PARK DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5746
Mailing Address - Country:US
Mailing Address - Phone:618-288-7991
Mailing Address - Fax:618-288-7901
Practice Address - Street 1:2 PROFESSIONAL PARK DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5746
Practice Address - Country:US
Practice Address - Phone:618-288-7991
Practice Address - Fax:618-288-7901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212556Medicare ID - Type Unspecified
ILK22512Medicare UPIN