Provider Demographics
NPI:1699725424
Name:TRI-STATE CLINIC OF CHIROPRACTIC, PC
Entity type:Organization
Organization Name:TRI-STATE CLINIC OF CHIROPRACTIC, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:HORRALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-262-2222
Mailing Address - Street 1:229 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:IL
Mailing Address - Zip Code:62863-1608
Mailing Address - Country:US
Mailing Address - Phone:618-262-2222
Mailing Address - Fax:618-262-2224
Practice Address - Street 1:229 W 2ND ST
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863-1608
Practice Address - Country:US
Practice Address - Phone:618-262-2222
Practice Address - Fax:618-262-2224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060009274111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213627Medicare UPIN