Provider Demographics
NPI:1396053005
Name:ZIMMERMAN CHIROPRACTIC CLINIC PC
Entity type:Organization
Organization Name:ZIMMERMAN CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCSP
Authorized Official - Phone:618-542-2165
Mailing Address - Street 1:7 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-1420
Mailing Address - Country:US
Mailing Address - Phone:618-542-2165
Mailing Address - Fax:618-542-9276
Practice Address - Street 1:7 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-1420
Practice Address - Country:US
Practice Address - Phone:618-542-2165
Practice Address - Fax:618-542-9276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038007421Medicaid
IL07308609OtherBLUE CROSS BLUE SHIELD
IL353021Medicare PIN
IL07308609OtherBLUE CROSS BLUE SHIELD