Provider Demographics
NPI:1801192554
Name:MESTDAGH CHIROPRACTIC CORP
Entity Type:Organization
Organization Name:MESTDAGH CHIROPRACTIC CORP
Other - Org Name:COLUMBIA CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MESTDAGH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-281-6167
Mailing Address - Street 1:1550 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-1070
Mailing Address - Country:US
Mailing Address - Phone:618-281-6167
Mailing Address - Fax:618-281-4444
Practice Address - Street 1:1550 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1070
Practice Address - Country:US
Practice Address - Phone:618-281-6167
Practice Address - Fax:618-281-4444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty