Provider Demographics
NPI:1316783178
Name:CHAMPAIGN CLINIC INC
Entity type:Organization
Organization Name:CHAMPAIGN CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:STACHNIK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-355-5922
Mailing Address - Street 1:1207 S MATTIS AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-4861
Mailing Address - Country:US
Mailing Address - Phone:217-355-5922
Mailing Address - Fax:217-355-5925
Practice Address - Street 1:1207 S MATTIS AVE STE 2
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-4861
Practice Address - Country:US
Practice Address - Phone:217-355-5922
Practice Address - Fax:217-355-5925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-02
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty