Provider Demographics
NPI:1881888105
Name:MOUNT VERNON CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:MOUNT VERNON CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-242-4554
Mailing Address - Street 1:1315 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-3720
Mailing Address - Country:US
Mailing Address - Phone:618-242-4554
Mailing Address - Fax:618-242-4653
Practice Address - Street 1:1315 MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-3720
Practice Address - Country:US
Practice Address - Phone:618-242-4554
Practice Address - Fax:618-242-4653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006100261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4182010OtherBLUE CROSS BLUE SHIELD
IL038006100Medicaid
IL350027546OtherPALMETTO RR MEDICARE
IL038006100Medicaid