Provider Demographics
NPI:1528072451
Name:GRANITE CITY CHIROPRACTIC LLC
Entity type:Organization
Organization Name:GRANITE CITY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-452-2300
Mailing Address - Street 1:258 GEREMMA DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3334
Mailing Address - Country:US
Mailing Address - Phone:314-283-8421
Mailing Address - Fax:
Practice Address - Street 1:3136 NAMEOKI RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-5013
Practice Address - Country:US
Practice Address - Phone:618-452-2300
Practice Address - Fax:618-452-0373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL06026803OtherBLUE CROSS & BLUE SHIELD
U81677Medicare UPIN
593100Medicare ID - Type Unspecified