Provider Demographics
NPI:1760594261
Name:DR THOMAS M KOVACIK
Entity Type:Organization
Organization Name:DR THOMAS M KOVACIK
Other - Org Name:KNOX COUNTY CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KOVACIK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-342-9147
Mailing Address - Street 1:1128 MONROE STREET
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401
Mailing Address - Country:US
Mailing Address - Phone:309-342-9147
Mailing Address - Fax:309-342-9147
Practice Address - Street 1:1128 MONROE STREET
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401
Practice Address - Country:US
Practice Address - Phone:309-342-9147
Practice Address - Fax:309-342-9147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038003797111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
791350632OtherRR MEDICARE
04832003OtherBCBS
791350632OtherRR MEDICARE