Provider Demographics
NPI:1659752095
Name:CORE PHYSICAL MEDICINE LLC
Entity type:Organization
Organization Name:CORE PHYSICAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:S
Authorized Official - Last Name:WORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-692-5555
Mailing Address - Street 1:PO BOX 23617
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-0617
Mailing Address - Country:US
Mailing Address - Phone:618-235-4357
Mailing Address - Fax:618-692-5034
Practice Address - Street 1:4 157 CTR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3657
Practice Address - Country:US
Practice Address - Phone:618-692-5555
Practice Address - Fax:618-692-5034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007715111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty