Provider Demographics
NPI:1972687457
Name:EVERINGHAM, JOHN MARVIN (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARVIN
Last Name:EVERINGHAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 VISA DR
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2131
Mailing Address - Country:US
Mailing Address - Phone:309-268-9000
Mailing Address - Fax:309-268-9003
Practice Address - Street 1:1603 VISA DR
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2131
Practice Address - Country:US
Practice Address - Phone:309-268-9000
Practice Address - Fax:309-268-9003
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-005103111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5715397OtherBCBS OF ILLINOIS
L55004Medicare UPIN
IL395230Medicare ID - Type Unspecified