Provider Demographics
NPI:1760712350
Name:FIRST CHOICE HEALTHCARE AND PHYSICAL MEDICINE SC
Entity Type:Organization
Organization Name:FIRST CHOICE HEALTHCARE AND PHYSICAL MEDICINE SC
Other - Org Name:FIRST CHOICE HEALTHCARE AND PHYSICAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-732-1111
Mailing Address - Street 1:714 N LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:IL
Mailing Address - Zip Code:62656-1741
Mailing Address - Country:US
Mailing Address - Phone:217-732-1111
Mailing Address - Fax:217-735-2744
Practice Address - Street 1:714 N LOGAN ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-1741
Practice Address - Country:US
Practice Address - Phone:217-732-1111
Practice Address - Fax:217-735-2744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-05
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.007869111N00000X
IL038.007886111N00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty