Provider Demographics
NPI:1730391269
Name:DOWNSTATE CHIROPRACTIC CENTER
Entity type:Organization
Organization Name:DOWNSTATE CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:K
Authorized Official - Last Name:KIDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-844-4631
Mailing Address - Street 1:214 NORTH LADD STREET
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764
Mailing Address - Country:US
Mailing Address - Phone:815-844-4631
Mailing Address - Fax:
Practice Address - Street 1:1002 COMMERCIAL DRIVE
Practice Address - Street 2:SUITE 4
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853
Practice Address - Country:US
Practice Address - Phone:217-586-7535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
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