Provider Demographics
NPI:1962403907
Name:CHIROMED LTD
Entity type:Organization
Organization Name:CHIROMED LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:JOSHUA
Authorized Official - Last Name:LAUX
Authorized Official - Suffix:SR
Authorized Official - Credentials:DC
Authorized Official - Phone:618-235-3200
Mailing Address - Street 1:3200 WEST MAIN ST REET
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226
Mailing Address - Country:US
Mailing Address - Phone:618-235-3200
Mailing Address - Fax:618-235-3282
Practice Address - Street 1:3200 WEST MAIN ST REET
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226
Practice Address - Country:US
Practice Address - Phone:618-235-3200
Practice Address - Fax:618-235-3282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-01
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL702160Medicare PIN