Provider Demographics
NPI:1104926344
Name:HYDE PARK CHIROPRACTIC WELLNESS CENTER SC
Entity type:Organization
Organization Name:HYDE PARK CHIROPRACTIC WELLNESS CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLANDE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BALAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-493-7034
Mailing Address - Street 1:1304 E 47TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-4695
Mailing Address - Country:US
Mailing Address - Phone:773-493-7034
Mailing Address - Fax:773-493-5521
Practice Address - Street 1:1304 E 47TH ST STE 201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-4695
Practice Address - Country:US
Practice Address - Phone:773-493-7034
Practice Address - Fax:773-493-5521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007681111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U66759Medicare UPIN
ILK30340Medicare UPIN