Provider Demographics
NPI:1720331721
Name:FEDDES CHIROPRACTIC LTD
Entity Type:Organization
Organization Name:FEDDES CHIROPRACTIC LTD
Other - Org Name:GOTTFRIED CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:CLARENCE
Authorized Official - Last Name:FEDDES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-691-2938
Mailing Address - Street 1:200 N WEST ST
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-1108
Mailing Address - Country:US
Mailing Address - Phone:618-395-9131
Mailing Address - Fax:
Practice Address - Street 1:200 N WEST ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-1108
Practice Address - Country:US
Practice Address - Phone:618-395-9131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012288111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty