Provider Demographics
NPI:1639394943
Name:MAIN STREET CHIROPRACTIC, P.C.
Entity type:Organization
Organization Name:MAIN STREET CHIROPRACTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:STUCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-230-9070
Mailing Address - Street 1:23915 W MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-1967
Mailing Address - Country:US
Mailing Address - Phone:815-230-9070
Mailing Address - Fax:815-230-9334
Practice Address - Street 1:23915 W MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-1967
Practice Address - Country:US
Practice Address - Phone:815-230-9070
Practice Address - Fax:815-230-9334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9932028OtherBLUE CROSS BLUE SHIELD
IL212074Medicare ID - Type Unspecified
IL9932028OtherBLUE CROSS BLUE SHIELD