Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | 038-008093 | IL |
NPI | 1306989884 |
---|---|
Provider Name | Dr. Jimmie E. Weathers JR. |
First Address | St Charles, IL 60174-5799 |
Second Address | St Charles, IL 60174-5799 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2007 |
Last Update Date | 01/06/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U67798 | (02) | IL |