Provider Demographics
NPI:1447559935
Name:WAYNE DAVIS CHIROPRACTIC INC
Entity Type:Organization
Organization Name:WAYNE DAVIS CHIROPRACTIC INC
Other - Org Name:MOLINE CHIROPRACTIC CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-650-4169
Mailing Address - Street 1:1715 5TH AVE A
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265
Mailing Address - Country:US
Mailing Address - Phone:563-650-4169
Mailing Address - Fax:
Practice Address - Street 1:1715 5TH AVE A
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265
Practice Address - Country:US
Practice Address - Phone:563-650-4169
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAYNE DAVIS CHIROPRACTIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-23
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011236111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty