Provider Demographics
NPI:1508120155
Name:VANCE CHIROPRACTIC AND WELLNESS
Entity Type:Organization
Organization Name:VANCE CHIROPRACTIC AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-357-2133
Mailing Address - Street 1:524 BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:IL
Mailing Address - Zip Code:62321-1307
Mailing Address - Country:US
Mailing Address - Phone:217-357-2133
Mailing Address - Fax:
Practice Address - Street 1:524 BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:IL
Practice Address - Zip Code:62321-1307
Practice Address - Country:US
Practice Address - Phone:217-357-2133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038003180111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4172OtherMEDICARE PTAN #