Provider Demographics
NPI:1679646822
Name:GILLIS, JOHN ALLEN (DC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALLEN
Last Name:GILLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 LATHAM AVE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-1637
Mailing Address - Country:US
Mailing Address - Phone:419-228-0000
Mailing Address - Fax:
Practice Address - Street 1:1905 LATHAM AVE
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-1637
Practice Address - Country:US
Practice Address - Phone:419-228-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1226111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH04754OtherPARAMOUNT
OH00000181391OtherANTHEM BLUE CROSS / BLUE SHIELD
OH31-1490432-004OtherMEDICAL MUTUAL
OH4598779OtherAETNA
OH5653880001Medicare NSC