Provider Demographics
NPI: | 1922287093 |
---|---|
Name: | BYRON L. PERRY DC PC INC |
Entity Type: | Organization |
Organization Name: | BYRON L. PERRY DC PC INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | BYRON |
Authorized Official - Middle Name: | LOUIS |
Authorized Official - Last Name: | PERRY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DC |
Authorized Official - Phone: | 815-434-0803 |
Mailing Address - Street 1: | 111 E CANAL AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | OTTAWA |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 61350-2111 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 815-434-0803 |
Mailing Address - Fax: | 815-434-0772 |
Practice Address - Street 1: | 111 E CANAL AVE |
Practice Address - Street 2: | |
Practice Address - City: | OTTAWA |
Practice Address - State: | IL |
Practice Address - Zip Code: | 61350-2111 |
Practice Address - Country: | US |
Practice Address - Phone: | 815-434-0803 |
Practice Address - Fax: | 815-434-0772 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-10-25 |
Last Update Date: | 2012-12-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 111N00000X | Chiropractic Providers | Chiropractor | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 213317 | Medicare PIN |