Provider Demographics
NPI:1487833992
Name:BLOOMINGTON CHIROPRACTIC CENTER, LTD.
Entity Type:Organization
Organization Name:BLOOMINGTON CHIROPRACTIC CENTER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR ASSOICATE
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:EVERINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-663-8388
Mailing Address - Street 1:409 S PROSPECT RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-4581
Mailing Address - Country:US
Mailing Address - Phone:309-663-8388
Mailing Address - Fax:309-663-0929
Practice Address - Street 1:409 S PROSPECT RD
Practice Address - Street 2:SUITE A
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4581
Practice Address - Country:US
Practice Address - Phone:309-663-8388
Practice Address - Fax:309-663-0929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060002911- 038007235261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5715397OtherBLUE CROSS / BLUE SHIED
IL5715397OtherBLUE CROSS / BLUE SHIED
IL395230Medicare PIN