Provider Demographics
NPI:1619267135
Name:GERGOVICH FAMILY CHIROPRACTIC, LLC.
Entity Type:Organization
Organization Name:GERGOVICH FAMILY CHIROPRACTIC, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GERGOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-228-8137
Mailing Address - Street 1:130 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-2312
Mailing Address - Country:US
Mailing Address - Phone:815-223-0647
Mailing Address - Fax:815-223-0987
Practice Address - Street 1:130 3RD ST
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301
Practice Address - Country:US
Practice Address - Phone:815-223-0647
Practice Address - Fax:815-223-0987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-18
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011831111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty