Provider Demographics
NPI:1629310313
Name:FRONTLINE CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:FRONTLINE CHIROPRACTIC CLINIC INC
Other - Org Name:FCC INC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-755-2311
Mailing Address - Street 1:723 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-2133
Mailing Address - Country:US
Mailing Address - Phone:309-755-2311
Mailing Address - Fax:
Practice Address - Street 1:723 15TH AVE
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-2133
Practice Address - Country:US
Practice Address - Phone:309-755-2311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-21
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012344111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty