Basic Information
Provider Information | |||||||||
NPI: | 1356358253 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VICK | ||||||||
FirstName: | LARRY | ||||||||
MiddleName: | B | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.C. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 916 TALON DRIVE | ||||||||
Address2: | SUITE 102 | ||||||||
City: | OFALLON | ||||||||
State: | IL | ||||||||
PostalCode: | 622691848 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6186288211 | ||||||||
FaxNumber: | 6186280883 | ||||||||
Practice Location | |||||||||
Address1: | 916 TALON DRIVE | ||||||||
Address2: | SUITE 102 | ||||||||
City: | OFALLON | ||||||||
State: | IL | ||||||||
PostalCode: | 622691848 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6186288211 | ||||||||
FaxNumber: | 6186280883 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2006 | ||||||||
LastUpdateDate: | 01/07/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 038003709 | IL | Y |   | Chiropractic Providers | Chiropractor |   |
ID Information
ID | Type | State | Issuer | Description | 08220357 | 01 | IL | BCBS GRP# | OTHER | 900068033 | 01 | IL | TAX ID# | OTHER |