Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | IL |
NPI | 1013014778 |
---|---|
Provider Name | Dr. Timothy John Mertes |
First Address | Peru, IL 61354-1385 |
Second Address | Peru, IL 61354-1385 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U87012 | (02) | IL |