Provider Demographics
NPI:1528017217
Name:CHIROPRACTIC & SPINAL CARE CLINIC OF MASCOUTAH
Entity Type:Organization
Organization Name:CHIROPRACTIC & SPINAL CARE CLINIC OF MASCOUTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESENDENT / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:BOLLENBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-566-3500
Mailing Address - Street 1:13166 PRAIRIE GRASS LN
Mailing Address - Street 2:
Mailing Address - City:BREESE
Mailing Address - State:IL
Mailing Address - Zip Code:62230-4328
Mailing Address - Country:US
Mailing Address - Phone:618-420-0409
Mailing Address - Fax:
Practice Address - Street 1:111 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-2110
Practice Address - Country:US
Practice Address - Phone:618-566-3500
Practice Address - Fax:618-566-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213424Medicare ID - Type UnspecifiedMEDICARE CORPORATION ID