Provider Demographics
NPI:1548357114
Name:MICHAEL J HEATWOLE CHIROPRACTIC INC
Entity type:Organization
Organization Name:MICHAEL J HEATWOLE CHIROPRACTIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JUSTIN
Authorized Official - Last Name:HEATWOLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-366-0066
Mailing Address - Street 1:7367 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1230
Mailing Address - Country:US
Mailing Address - Phone:708-366-0066
Mailing Address - Fax:708-366-0044
Practice Address - Street 1:7367 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1230
Practice Address - Country:US
Practice Address - Phone:708-366-0066
Practice Address - Fax:708-366-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010455111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK25187Medicare PIN