Provider Demographics
NPI:1780760413
Name:QUIRAM SPINAL & SPORTS REHABILITATION LTD
Entity type:Organization
Organization Name:QUIRAM SPINAL & SPORTS REHABILITATION LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:QUIRAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-662-6462
Mailing Address - Street 1:21108 N 25 EAST ROAD
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:IL
Mailing Address - Zip Code:61732-4497
Mailing Address - Country:US
Mailing Address - Phone:309-662-6462
Mailing Address - Fax:309-965-2384
Practice Address - Street 1:21108 N 25 EAST ROAD
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:IL
Practice Address - Zip Code:61732-4497
Practice Address - Country:US
Practice Address - Phone:309-662-6462
Practice Address - Fax:309-965-2384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-617717111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5732002OtherBLUE CROSS BLUE SHIELD
IL5732002OtherBLUE CROSS BLUE SHIELD