Provider Demographics
NPI:1619195450
Name:OLIVER, MICHELLE ELLEN (DC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELLEN
Last Name:OLIVER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3631 S 6TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-4777
Mailing Address - Country:US
Mailing Address - Phone:217-391-5446
Mailing Address - Fax:217-585-6720
Practice Address - Street 1:3631 S 6TH ST STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-4777
Practice Address - Country:US
Practice Address - Phone:217-391-5446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2023-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008294111NN1001X, 111NP0017X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN1001XChiropractic ProvidersChiropractorNutrition
No111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL75744Medicare PIN
IL569590Medicare ID - Type UnspecifiedMEDICARE GROUP #
ILU71142Medicare UPIN