Provider Demographics
NPI:1386107217
Name:HOLTSCHLAG, CLARENCE
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:
Last Name:HOLTSCHLAG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-5655
Mailing Address - Country:US
Mailing Address - Phone:217-228-2040
Mailing Address - Fax:
Practice Address - Street 1:2000 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-5655
Practice Address - Country:US
Practice Address - Phone:217-228-2040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013356111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor