Provider Demographics
NPI:1487623302
Name:VILLA PARK CHIROPRACTIC CENTER, LTD.
Entity type:Organization
Organization Name:VILLA PARK CHIROPRACTIC CENTER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUTHER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-691-1234
Mailing Address - Street 1:411 W SAINT CHARLES RD
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-2432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 W SAINT CHARLES RD
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-2432
Practice Address - Country:US
Practice Address - Phone:630-691-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02232410OtherBCBSIL
IL02232410OtherBCBSIL
ILP00120402Medicare PIN
IL203798Medicare ID - Type Unspecified