Provider Demographics
NPI:1528422235
Name:TCWC GLEN CARBON, LLC
Entity type:Organization
Organization Name:TCWC GLEN CARBON, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:T
Authorized Official - Last Name:CLAYWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-792-2762
Mailing Address - Street 1:1901 CHEYENNE DR
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-1532
Mailing Address - Country:US
Mailing Address - Phone:618-792-2762
Mailing Address - Fax:636-978-7570
Practice Address - Street 1:11 GINGER CREEK VLG
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-3517
Practice Address - Country:US
Practice Address - Phone:618-307-9540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-08
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012948111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1689066573OtherINDIVIDUAL NPI