Provider Demographics
NPI:1346362589
Name:BLACKWOOD CHIROPRACTIC, PLLC
Entity type:Organization
Organization Name:BLACKWOOD CHIROPRACTIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERAMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-520-0222
Mailing Address - Street 1:222 10TH AVE E
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:IL
Mailing Address - Zip Code:61264-3120
Mailing Address - Country:US
Mailing Address - Phone:309-520-0222
Mailing Address - Fax:309-520-0223
Practice Address - Street 1:222 10TH AVE E
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:IL
Practice Address - Zip Code:61264-3120
Practice Address - Country:US
Practice Address - Phone:309-520-0222
Practice Address - Fax:309-520-0223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2025-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X, 261QH0100X
IL070014182225100000X
IL041171677363LF0000X
IL036113072208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209030400OtherDEPARTMENT OF LABOR ID
IL8132027OtherBLUE SHIELD FACILITY ID
IL208225Medicare ID - Type Unspecified