Provider Demographics
NPI:1215277967
Name:SOUTHERN ILLINOIS SPORT AND SPINE LLC
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS SPORT AND SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:KOEHN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-521-0552
Mailing Address - Street 1:106 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-1337
Mailing Address - Country:US
Mailing Address - Phone:618-435-3888
Mailing Address - Fax:
Practice Address - Street 1:106 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-1337
Practice Address - Country:US
Practice Address - Phone:618-435-3888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-17
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012350111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty