Provider Demographics
NPI:1932671666
Name:ILLUMINATE CHIROPRACTIC
Entity Type:Organization
Organization Name:ILLUMINATE CHIROPRACTIC
Other - Org Name:ILLUMINATE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LONI
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MCCLELLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-606-2023
Mailing Address - Street 1:810 DOMINICAN DR STE 106
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37228-1906
Mailing Address - Country:US
Mailing Address - Phone:615-606-2023
Mailing Address - Fax:
Practice Address - Street 1:810 DOMINICAN DR STE 106
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37228-1906
Practice Address - Country:US
Practice Address - Phone:615-606-2023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-19
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3125OtherSTATE LICENSE