Provider Demographics
NPI:1124152699
Name:ILLINOIS SPINE CENTER SC
Entity type:Organization
Organization Name:ILLINOIS SPINE CENTER SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:ERICK
Authorized Official - Last Name:CLEM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-438-6324
Mailing Address - Street 1:2700 W LAWRENCE AVE STE J4
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7201
Mailing Address - Country:US
Mailing Address - Phone:217-546-6698
Mailing Address - Fax:217-438-6532
Practice Address - Street 1:2700 W LAWRENCE AVE STE J4
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7201
Practice Address - Country:US
Practice Address - Phone:217-546-6698
Practice Address - Fax:217-438-6532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009051111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU79997Medicare UPIN
IL213005Medicare ID - Type Unspecified