Provider Demographics
NPI:1861675217
Name:ANDALUSIA FAMILY CHIROPRACTIC PC
Entity Type:Organization
Organization Name:ANDALUSIA FAMILY CHIROPRACTIC PC
Other - Org Name:ANDALUSIA FAMILY CHIROPRACTIC PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BISBY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-798-5555
Mailing Address - Street 1:326 6TH AVE WEST SUITE 1
Mailing Address - Street 2:PO BOX 555
Mailing Address - City:ANDALUSIA
Mailing Address - State:IL
Mailing Address - Zip Code:61232-0555
Mailing Address - Country:US
Mailing Address - Phone:309-798-5555
Mailing Address - Fax:309-798-5205
Practice Address - Street 1:326 6TH AVE WEST
Practice Address - Street 2:SUITE 1
Practice Address - City:ANDALUSIA
Practice Address - State:IL
Practice Address - Zip Code:61232-0555
Practice Address - Country:US
Practice Address - Phone:309-798-5555
Practice Address - Fax:309-798-5205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-010216111N00000X
IL060-009615111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty