Provider Demographics
NPI:1871691410
Name:HEALTHFRIST 001 LLC
Entity type:Organization
Organization Name:HEALTHFRIST 001 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:P
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-854-3300
Mailing Address - Street 1:110 E 1ST NORTH ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1505
Mailing Address - Country:US
Mailing Address - Phone:217-854-3300
Mailing Address - Fax:217-854-4546
Practice Address - Street 1:700 GARLINGTON RD STE G
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-5435
Practice Address - Country:US
Practice Address - Phone:864-281-9393
Practice Address - Fax:864-281-9394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3176111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8588Medicare PIN