Basic Information
| Provider Information | |||||||||
| NPI: | 1073880423 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UPPER CERVICAL CARE OF ALTON LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 PROFESSIONAL DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184657177 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3 PROFESSIONAL DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184657177 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2011 | ||||||||
| LastUpdateDate: | 11/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | BUENGER | ||||||||
| AuthorizedOfficialFirstName: | WYNNDEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6184657177 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PIASA PAIN CENTER LLC | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | 038008971 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.