Provider Demographics
NPI:1972893121
Name:SOUTHPARK CHIROPRACTIC WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:SOUTHPARK CHIROPRACTIC WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:FIXEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-757-7100
Mailing Address - Street 1:1529 46TH AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-7084
Mailing Address - Country:US
Mailing Address - Phone:309-757-7100
Mailing Address - Fax:309-757-7111
Practice Address - Street 1:1529 46TH AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-7084
Practice Address - Country:US
Practice Address - Phone:309-757-7100
Practice Address - Fax:309-757-7111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011683261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care