Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0400X | Rehabilitation Chiropractor | 038-010047 | IL |
NPI | 1083767727 |
---|---|
Provider Name | Dr. James Edgar Wayne Drake |
First Address | Cherry Valley, IL 61016-9372 |
Second Address | Cherry Valley, IL 61016-9372 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/01/2007 |
Last Update Date | 27/06/2012 |