Provider Demographics
NPI:1669453056
Name:ANDINO CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:ANDINO CHIROPRACTIC CLINIC PC
Other - Org Name:HEALTH FIRST WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ANDINO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-877-5575
Mailing Address - Street 1:7264 ARGUS DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5837
Mailing Address - Country:US
Mailing Address - Phone:815-877-5575
Mailing Address - Fax:815-877-5550
Practice Address - Street 1:7264 ARGUS DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5837
Practice Address - Country:US
Practice Address - Phone:815-877-5575
Practice Address - Fax:815-877-5550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010991111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U32828Medicare UPIN
IL207944Medicare ID - Type Unspecified