Provider Demographics
NPI:1528250651
Name:DEPEW FAMILY CHIROPRACTIC, P.C.
Entity type:Organization
Organization Name:DEPEW FAMILY CHIROPRACTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:DEPEW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-346-2663
Mailing Address - Street 1:3299 COURT ST
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-6208
Mailing Address - Country:US
Mailing Address - Phone:309-346-2663
Mailing Address - Fax:309-346-2680
Practice Address - Street 1:3299 COURT ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-6208
Practice Address - Country:US
Practice Address - Phone:309-346-2663
Practice Address - Fax:309-346-2680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU98786Medicare UPIN
IL207434Medicare PIN