Provider Demographics
NPI:1972599579
Name:CLARKE & GULLA CHIROPRACTIC, LTD
Entity Type:Organization
Organization Name:CLARKE & GULLA CHIROPRACTIC, LTD
Other - Org Name:CENTRAL CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBROUGH
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-255-0606
Mailing Address - Street 1:521 W. CENTRAL RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056
Mailing Address - Country:US
Mailing Address - Phone:847-255-0606
Mailing Address - Fax:847-255-0794
Practice Address - Street 1:521 W. CENTRAL RD
Practice Address - Street 2:SUITE 2
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056
Practice Address - Country:US
Practice Address - Phone:847-255-0606
Practice Address - Fax:847-255-0794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208276Medicare ID - Type UnspecifiedGROUP NUMBER