Provider Demographics
NPI:1366980203
Name:MICNHEIMER, NEIL LEON (DC)
Entity type:Individual
Prefix:DR
First Name:NEIL
Middle Name:LEON
Last Name:MICNHEIMER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW DOUGLAS
Mailing Address - State:IL
Mailing Address - Zip Code:62074-1622
Mailing Address - Country:US
Mailing Address - Phone:618-690-5100
Mailing Address - Fax:618-690-5101
Practice Address - Street 1:122 S 2ND ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1723
Practice Address - Country:US
Practice Address - Phone:618-690-5100
Practice Address - Fax:618-690-5101
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038013077111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor