Provider Demographics
NPI:1336535608
Name:ETHEN CHIROPRACTIC AND WELLNESS
Entity type:Organization
Organization Name:ETHEN CHIROPRACTIC AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ETHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-835-4700
Mailing Address - Street 1:630 VERNON AVE STE F
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:IL
Mailing Address - Zip Code:60022-1689
Mailing Address - Country:US
Mailing Address - Phone:847-835-4700
Mailing Address - Fax:847-835-8408
Practice Address - Street 1:630 VERNON AVE STE F
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:IL
Practice Address - Zip Code:60022-1689
Practice Address - Country:US
Practice Address - Phone:847-835-4700
Practice Address - Fax:847-835-8408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011678111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty