Provider Demographics
NPI:1497955264
Name:TAYLORVILLE LIFELONG CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:TAYLORVILLE LIFELONG CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERCHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:PICONE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-287-1040
Mailing Address - Street 1:400 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-2188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 W MARKET ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-2188
Practice Address - Country:US
Practice Address - Phone:217-287-1040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010164305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01132002OtherBLUE CROSS BLUE SHIELD OF
IL209705Medicare PIN