Provider Demographics
NPI:1629272133
Name:STAUNTON CHIROPRACTIC CLINIC, INC.
Entity Type:Organization
Organization Name:STAUNTON CHIROPRACTIC CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROLLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-635-3200
Mailing Address - Street 1:426 W PEARL ST
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:IL
Mailing Address - Zip Code:62088-1313
Mailing Address - Country:US
Mailing Address - Phone:618-635-3200
Mailing Address - Fax:618-635-5445
Practice Address - Street 1:426 W PEARL ST
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:IL
Practice Address - Zip Code:62088-1313
Practice Address - Country:US
Practice Address - Phone:618-635-3200
Practice Address - Fax:618-635-5445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38-009779111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210315Medicare ID - Type Unspecified