Provider Demographics
NPI:1457419566
Name:KHAIRALLAH CHIROPRACTIC PC
Entity Type:Organization
Organization Name:KHAIRALLAH CHIROPRACTIC PC
Other - Org Name:JSK CHIROPRACTIC PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:KHAIRALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-679-9575
Mailing Address - Street 1:4501 N STERLING AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-3834
Mailing Address - Country:US
Mailing Address - Phone:309-679-9575
Mailing Address - Fax:
Practice Address - Street 1:4501 N STERLING AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-3834
Practice Address - Country:US
Practice Address - Phone:309-679-9575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07232021OtherBLUE CROSS BLUE SHIELD
IL210101Medicare ID - Type Unspecified