Provider Demographics
NPI:1407143571
Name:ZIDEK CHIROPRACTIC CENTER PC
Entity type:Organization
Organization Name:ZIDEK CHIROPRACTIC CENTER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:ZIDEK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-774-4616
Mailing Address - Street 1:522 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62565-1401
Mailing Address - Country:US
Mailing Address - Phone:217-774-4616
Mailing Address - Fax:217-774-4844
Practice Address - Street 1:522 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62565-1401
Practice Address - Country:US
Practice Address - Phone:217-774-4616
Practice Address - Fax:217-774-4844
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ZIDEK CHIROPRACTIC CENTER PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038003467111N00000X
IL038010544111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210136Medicare PIN