Provider Demographics
NPI:1881853257
Name:WITTENAUER CHIROPRACTIC PC
Entity type:Organization
Organization Name:WITTENAUER CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:WITTENAUER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-357-3089
Mailing Address - Street 1:103 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PINCKNEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62274-1141
Mailing Address - Country:US
Mailing Address - Phone:618-357-5012
Mailing Address - Fax:
Practice Address - Street 1:103 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:PINCKNEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62274-1141
Practice Address - Country:US
Practice Address - Phone:618-357-5012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-007782111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038-007782Medicaid
IL038-007782Medicaid