Provider Demographics
NPI:1568865707
Name:FAIRBURY CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:FAIRBURY CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:J
Authorized Official - Last Name:NOWAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-692-2373
Mailing Address - Street 1:401 S CLAY ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:IL
Mailing Address - Zip Code:61739-1481
Mailing Address - Country:US
Mailing Address - Phone:815-692-2373
Mailing Address - Fax:815-692-2374
Practice Address - Street 1:401 S CLAY ST
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:IL
Practice Address - Zip Code:61739-1481
Practice Address - Country:US
Practice Address - Phone:815-692-2373
Practice Address - Fax:815-692-2374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007108111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU36370Medicare UPIN