Provider Demographics
NPI:1659450815
Name:KOEHLER SPORTS & SPINAL REHAB LTD
Entity Type:Organization
Organization Name:KOEHLER SPORTS & SPINAL REHAB LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:KOEHLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC CCSP
Authorized Official - Phone:815-939-4900
Mailing Address - Street 1:232 MAIN NW
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914
Mailing Address - Country:US
Mailing Address - Phone:815-939-4900
Mailing Address - Fax:815-939-4951
Practice Address - Street 1:232 MAIN ST NW
Practice Address - Street 2:SUITE 201
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1938
Practice Address - Country:US
Practice Address - Phone:815-939-4900
Practice Address - Fax:815-939-4951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038005929111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03800J929Medicaid
T87128Medicare UPIN
IL03800J929Medicaid
209811Medicare ID - Type UnspecifiedGR