Provider Demographics
NPI:1629576954
Name:JLDC INC.
Entity Type:Organization
Organization Name:JLDC INC.
Other - Org Name:OPTIMAL SPINE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:WIEDRICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-906-0090
Mailing Address - Street 1:2031 E GRAND AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-9094
Mailing Address - Country:US
Mailing Address - Phone:843-906-0090
Mailing Address - Fax:
Practice Address - Street 1:2031 E GRAND AVE STE 301
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-9094
Practice Address - Country:US
Practice Address - Phone:843-906-0090
Practice Address - Fax:843-906-0090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-01
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.010896111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty