Provider Demographics
NPI:1700098902
Name:RIDGE CHIROPRACTIC CENTER, LTD.
Entity Type:Organization
Organization Name:RIDGE CHIROPRACTIC CENTER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CISSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-467-1464
Mailing Address - Street 1:434 W. MONDAMIN ST.
Mailing Address - Street 2:
Mailing Address - City:MINOOKA
Mailing Address - State:IL
Mailing Address - Zip Code:60447
Mailing Address - Country:US
Mailing Address - Phone:815-467-1464
Mailing Address - Fax:815-521-0492
Practice Address - Street 1:434 W MONDAMIN ST
Practice Address - Street 2:
Practice Address - City:MINOOKA
Practice Address - State:IL
Practice Address - Zip Code:60447-9875
Practice Address - Country:US
Practice Address - Phone:815-467-1464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009977111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty