Provider Demographics
NPI:1285962662
Name:MIDWEST CLINIC OF CHIROPRACTIC, P.C.
Entity type:Organization
Organization Name:MIDWEST CLINIC OF CHIROPRACTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:HUNTSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-741-3939
Mailing Address - Street 1:2206 WEBER RD
Mailing Address - Street 2:
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60403-0928
Mailing Address - Country:US
Mailing Address - Phone:815-741-3939
Mailing Address - Fax:815-741-3949
Practice Address - Street 1:2206 WEBER RD
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-0928
Practice Address - Country:US
Practice Address - Phone:815-741-3939
Practice Address - Fax:815-741-3949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010492111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty