Provider Demographics
NPI:1740454065
Name:DR DAN KHAMPRASEUT
Entity type:Organization
Organization Name:DR DAN KHAMPRASEUT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAMPRASEUT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-233-3324
Mailing Address - Street 1:3620A N BELT W
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5947
Mailing Address - Country:US
Mailing Address - Phone:618-233-3324
Mailing Address - Fax:618-233-4758
Practice Address - Street 1:3620A N BELT W
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5947
Practice Address - Country:US
Practice Address - Phone:618-233-3324
Practice Address - Fax:618-233-4758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08009696Medicaid
IL8232072OtherBCBS-IL
IL08009696Medicaid