Provider Demographics
NPI:1831154434
Name:PURI, VIJAY ROCK (DC)
Entity type:Individual
Prefix:
First Name:VIJAY
Middle Name:ROCK
Last Name:PURI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3913 15TH STREET D
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265
Mailing Address - Country:US
Mailing Address - Phone:309-797-4062
Mailing Address - Fax:309-797-3795
Practice Address - Street 1:3913 15TH STREET D
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265
Practice Address - Country:US
Practice Address - Phone:309-797-4062
Practice Address - Fax:309-797-3795
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5652720OtherFIRST HEALTH
IL8132087OtherBLUE CROSS
IL5652720OtherFIRST HEALTH