Illinois Valley Chiropractic, LTD
Organization Active NPI Sports Physician Chiropractor · La Salle, IL
NPI 1679883185 · NPPES record last updated Oct 18, 2010
Key facts
- NPI
- 1679883185
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Sports Physician Chiropractor 111NS0005X
- License
- 038.008373 (IL)
- Legal business name
- ILLINOIS VALLEY CHIROPRACTIC, LTD
- Practice address
- 501 1St St
La Salle, IL 61301-2416 - Phone
- (815) 223-4201
- Fax
- (815) 223-4210
- NPI assigned
- Oct 18, 2010
- Organization subpart
- No
Authorized official
- Name
- Dr. Glen R Peterson, D.C.
- Title
- President
- Phone
- (815) 223-4201
Practitioners 1
-
Glen R Peterson, D.C.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20101216000039 | IL | Part B Supplier - Clinic/Group Practice | 5991993016 |
Receives reassigned benefits from 1 practitioner Practice locations: La Salle, IL |
National Provider Directory
Locations
501 1st St
La Salle, IL 61301
Phone (815) 223-4201
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Sports Physician Chiropractor |
111NS0005X | 038.008373 | IL | Yes |
Addresses
Primary practice location
501 1St St
La Salle, IL 61301-2416
Mailing address
PO Box 1204
La Salle, IL 61301-3204
Phone (815) 223-4201
Other providers in La Salle, IL
- Debra Kay Hultine
- Bayrnadette Humilde
- Jani Hurst
- Janet Christyne Hutchins
- Hygienic Institute for Lasalle, Peru and Oglesby
- Illinois Valley City Cab, Inc
- Illinois Veterans Home at Lasalle
- Brooklyn Rose Jakse
- Lexanne Jarosz
- Shannon Jenkins-Solomon
All providers in La Salle, IL · Sports Physician Chiropractor in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 18, 2010. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.