Provider Demographics
NPI:1821199381
Name:GREEN, JOHN ROGER (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROGER
Last Name:GREEN
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 1:212 1/2 NW 1ST ST
Mailing Address - Street 2:P O BOX 46
Mailing Address - City:GALVA
Mailing Address - State:IL
Mailing Address - Zip Code:61434-1380
Mailing Address - Country:US
Mailing Address - Phone:309-932-8505
Mailing Address - Fax:309-932-8505
Practice Address - Street 1:212 1/2 NW 1ST ST
Practice Address - Street 2:
Practice Address - City:GALVA
Practice Address - State:IL
Practice Address - Zip Code:61434-1380
Practice Address - Country:US
Practice Address - Phone:309-932-8505
Practice Address - Fax:309-932-8505
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009663111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3732006OtherBLUE CROSS PROVIDER NO.
IL3732006OtherBLUE CROSS PROVIDER NO.
IL210644Medicare ID - Type UnspecifiedPROVIDER NUMBER