Provider Demographics
NPI:1457458697
Name:GHOLSON CHIROPRACTIC LIFE & HEALTH LTD
Entity Type:Organization
Organization Name:GHOLSON CHIROPRACTIC LIFE & HEALTH LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:RHINE
Authorized Official - Last Name:GHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-384-2631
Mailing Address - Street 1:1624 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARMI
Mailing Address - State:IL
Mailing Address - Zip Code:62821-2235
Mailing Address - Country:US
Mailing Address - Phone:618-384-2631
Mailing Address - Fax:618-384-2908
Practice Address - Street 1:1624 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-2235
Practice Address - Country:US
Practice Address - Phone:618-384-3621
Practice Address - Fax:618-384-2908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008660111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038008660Medicaid
IL09726159OtherBLUE CROSS SHIELD IL
IL038008660Medicaid
IL09726159OtherBLUE CROSS SHIELD IL