Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | IL |
NPI | 1003839507 |
---|---|
Provider Name | Mr. John W. Birly |
First Address | Rockford, IL 61107-6657 |
Second Address | Rockford, IL 61107-6657 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T37182 | (02) | IL |