Provider Demographics
NPI:1700930559
Name:FLOCK, THEA C (DC)
Entity Type:Individual
Prefix:DR
First Name:THEA
Middle Name:C
Last Name:FLOCK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 N ILLINOIS ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-1500
Mailing Address - Country:US
Mailing Address - Phone:618-641-9595
Mailing Address - Fax:618-300-3736
Practice Address - Street 1:4505 N ILLINOIS ST
Practice Address - Street 2:SUITE 1
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-1500
Practice Address - Country:US
Practice Address - Phone:618-641-9595
Practice Address - Fax:618-300-3736
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.008004111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09932027OtherBCBS PROVIDER #
K08411Medicare PIN
P00144113Medicare PIN
IL09932027OtherBCBS PROVIDER #