Provider Demographics
NPI:1922385152
Name:WATERLOO CHIROPRACTIC AND REHABILITATION CENTER P.C.
Entity Type:Organization
Organization Name:WATERLOO CHIROPRACTIC AND REHABILITATION CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLEROY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-939-4700
Mailing Address - Street 1:305 S MOORE ST STE A
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1328
Mailing Address - Country:US
Mailing Address - Phone:618-939-4700
Mailing Address - Fax:
Practice Address - Street 1:305 S MOORE ST STE A
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1328
Practice Address - Country:US
Practice Address - Phone:618-939-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009945261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206408Medicare PIN