Provider Demographics
NPI:1346465572
Name:CONKLING CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:CONKLING CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:B
Authorized Official - Last Name:CONKLING III
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-332-1212
Mailing Address - Street 1:1407 CAMP JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:CAHOKIA
Mailing Address - State:IL
Mailing Address - Zip Code:62206-2501
Mailing Address - Country:US
Mailing Address - Phone:618-332-1212
Mailing Address - Fax:618-332-1214
Practice Address - Street 1:1407 CAMP JACKSON RD
Practice Address - Street 2:
Practice Address - City:CAHOKIA
Practice Address - State:IL
Practice Address - Zip Code:62206-2501
Practice Address - Country:US
Practice Address - Phone:618-332-1212
Practice Address - Fax:618-332-1214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8215155OtherLICENSE NUMBER
IL683460Medicare ID - Type UnspecifiedMEDICARE