Provider Demographics
NPI:1467677179
Name:JORDAHL CHIROPRACTIC & REHABILITATION CLINIC, INC
Entity Type:Organization
Organization Name:JORDAHL CHIROPRACTIC & REHABILITATION CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:JORDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-892-5770
Mailing Address - Street 1:1640 E GROVE AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61866
Mailing Address - Country:US
Mailing Address - Phone:217-892-5770
Mailing Address - Fax:217-893-4316
Practice Address - Street 1:1640 E GROVE AVE
Practice Address - Street 2:
Practice Address - City:RANTOUL
Practice Address - State:IL
Practice Address - Zip Code:61866-2737
Practice Address - Country:US
Practice Address - Phone:217-892-5770
Practice Address - Fax:217-893-4316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-006955111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL973742Medicare ID - Type Unspecified