Provider Demographics
NPI:1013098854
Name:SOUTHERN ILLINOIS SPINE & JOINT CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS SPINE & JOINT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:REISS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-443-2026
Mailing Address - Street 1:202 W JACKSON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SPARTA
Mailing Address - State:IL
Mailing Address - Zip Code:62286-1676
Mailing Address - Country:US
Mailing Address - Phone:618-443-2026
Mailing Address - Fax:
Practice Address - Street 1:202 W JACKSON ST
Practice Address - Street 2:SUITE A
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286-1676
Practice Address - Country:US
Practice Address - Phone:618-443-2026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-010604111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty