Provider Demographics
NPI:1437249158
Name:KOMESHAK CHIROPRACTIC LTD
Entity Type:Organization
Organization Name:KOMESHAK CHIROPRACTIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:KOMESHAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-236-3600
Mailing Address - Street 1:3030 FRANK SCOTT PKWY W
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5014
Mailing Address - Country:US
Mailing Address - Phone:618-236-3600
Mailing Address - Fax:618-236-3600
Practice Address - Street 1:3030 FRANK SCOTT PKWY W
Practice Address - Street 2:SUITE 1
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5014
Practice Address - Country:US
Practice Address - Phone:618-236-3600
Practice Address - Fax:618-236-3600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008047111N00000X
IL070011807225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DD4196OtherMEDICARE RAILROAD
104259OtherGHP
IL08221308OtherBCBS ILLINOIS
DD4196OtherMEDICARE RAILROAD