Provider Demographics
NPI:1487887279
Name:ADVANCED CHIRO-MED PAIN AND DIET CENTER, SC
Entity type:Organization
Organization Name:ADVANCED CHIRO-MED PAIN AND DIET CENTER, SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DYER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-544-3894
Mailing Address - Street 1:860 BIESTER DR
Mailing Address - Street 2:STE 103
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-4053
Mailing Address - Country:US
Mailing Address - Phone:815-544-3894
Mailing Address - Fax:815-547-3968
Practice Address - Street 1:860 BIESTER DR
Practice Address - Street 2:STE 103
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-4053
Practice Address - Country:US
Practice Address - Phone:815-544-3894
Practice Address - Fax:815-547-3968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007076111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05207617OtherBLUECROSS/BLUESHEILD
IL05207617OtherBLUECROSS/BLUESHEILD