Provider Demographics
NPI:1295790830
Name:MT. CARMEL CHIROPRACTIC CLINIC, S.C.
Entity type:Organization
Organization Name:MT. CARMEL CHIROPRACTIC CLINIC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGIL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:POTTS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-262-2225
Mailing Address - Street 1:616 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:IL
Mailing Address - Zip Code:62863-1459
Mailing Address - Country:US
Mailing Address - Phone:618-262-2225
Mailing Address - Fax:618-262-2880
Practice Address - Street 1:616 N MARKET ST
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863-1459
Practice Address - Country:US
Practice Address - Phone:618-262-2225
Practice Address - Fax:618-262-2880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-617767111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9321700OtherBLUE CROSS BLUE SHIELD
IL375772OtherHEALTHLINK
ILU68432Medicare UPIN
IL702330Medicare ID - Type UnspecifiedMEDICARE