Provider Demographics
NPI:1982613584
Name:INTEGRATIVE CHIROPRACTIC & SPORTS MEDICINE, LTD
Entity Type:Organization
Organization Name:INTEGRATIVE CHIROPRACTIC & SPORTS MEDICINE, LTD
Other - Org Name:INTEGRATIVE SPINAL & SPORTS REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:EASTERDAY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-439-9800
Mailing Address - Street 1:13520 S. ROUTE 59
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544
Mailing Address - Country:US
Mailing Address - Phone:815-439-9800
Mailing Address - Fax:815-439-9804
Practice Address - Street 1:13520 S. ROUTE 59
Practice Address - Street 2:SUITE 100
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544
Practice Address - Country:US
Practice Address - Phone:815-439-9800
Practice Address - Fax:815-439-9804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009675111N00000X
IL038.009675111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210991Medicare PIN
ILK14752Medicare UPIN