Provider Demographics
NPI:1861542094
Name:AMES, LAURA ROSE (DC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ROSE
Last Name:AMES
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 W VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2255
Mailing Address - Country:US
Mailing Address - Phone:217-347-5455
Mailing Address - Fax:
Practice Address - Street 1:1010 W JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2035
Practice Address - Country:US
Practice Address - Phone:217-347-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-005605111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK37517Medicare UPIN