Provider Demographics
NPI:1902117237
Name:PROGRESSIVE SPINE & JOINT CENTER LLC
Entity Type:Organization
Organization Name:PROGRESSIVE SPINE & JOINT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:VICKERY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-622-0096
Mailing Address - Street 1:4965 STONE FALLS CTR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7803
Mailing Address - Country:US
Mailing Address - Phone:618-622-0096
Mailing Address - Fax:618-624-9386
Practice Address - Street 1:4965 STONE FALLS CTR
Practice Address - Street 2:SUITE 3
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-7803
Practice Address - Country:US
Practice Address - Phone:618-622-0096
Practice Address - Fax:618-624-9386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-01
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011632111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4535Medicare PIN