Provider Demographics
NPI:1285873927
Name:ANDINO CHIROPRACTIC
Entity type:Organization
Organization Name:ANDINO CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDINO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-397-7889
Mailing Address - Street 1:2846 LANGSTONE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61109-1771
Mailing Address - Country:US
Mailing Address - Phone:815-397-7889
Mailing Address - Fax:
Practice Address - Street 1:2846 LANGSTONE DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61109-1771
Practice Address - Country:US
Practice Address - Phone:815-397-7889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009900111N00000X
IL038010991111NP0017X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NP0017XChiropractic ProvidersChiropractorPediatric ChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
11540208OtherCAQH