Provider Demographics
NPI:1194995217
Name:WALNUT CHIROPRACTIC AND ACUPUNCTURE, SC
Entity type:Organization
Organization Name:WALNUT CHIROPRACTIC AND ACUPUNCTURE, SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:DYER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-544-3894
Mailing Address - Street 1:887 WHITE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-9057
Mailing Address - Country:US
Mailing Address - Phone:815-652-3551
Mailing Address - Fax:
Practice Address - Street 1:860 BIESTER DR
Practice Address - Street 2:SUITE 103
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-4053
Practice Address - Country:US
Practice Address - Phone:815-544-3894
Practice Address - Fax:815-547-3968
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALNUT CHIROPRACTIC AND ACUPUNCTURE, SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-04
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007076111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05207617OtherBLUECROSS/BLUESHIELD
IL05207617OtherBLUECROSS/BLUESHIELD
IL987361Medicare PIN