Provider Demographics
NPI:1790806636
Name:BUSHNELL CHIROPRACTIC CENTER SC
Entity Type:Organization
Organization Name:BUSHNELL CHIROPRACTIC CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTOPHER
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:WAKEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-772-2317
Mailing Address - Street 1:448 COLE ST
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:IL
Mailing Address - Zip Code:61422-1540
Mailing Address - Country:US
Mailing Address - Phone:309-772-2317
Mailing Address - Fax:309-772-2317
Practice Address - Street 1:448 COLE ST
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:IL
Practice Address - Zip Code:61422-1540
Practice Address - Country:US
Practice Address - Phone:309-772-2317
Practice Address - Fax:309-772-2317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5522061Medicare PIN