Provider Demographics
NPI:1396169918
Name:FAMILY CHIROPRACTIC HEALTH AND NUTRITION, P.C.
Entity type:Organization
Organization Name:FAMILY CHIROPRACTIC HEALTH AND NUTRITION, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:EISELT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-647-3502
Mailing Address - Street 1:45 E SIDE SQ STE 101
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2671
Mailing Address - Country:US
Mailing Address - Phone:309-647-3502
Mailing Address - Fax:
Practice Address - Street 1:45 E SIDE SQ STE 101
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2671
Practice Address - Country:US
Practice Address - Phone:309-647-3502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY CHIROPRACTIC HEALTH AND NUTRITION, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-18
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011266111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038011266Medicaid