Provider Demographics
NPI:1699924084
Name:HARTLEY, KEITH ROBERT (DC)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ROBERT
Last Name:HARTLEY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4913 N ASHLAND AVE
Mailing Address - Street 2:UNIT 3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3416
Mailing Address - Country:US
Mailing Address - Phone:630-205-9601
Mailing Address - Fax:
Practice Address - Street 1:1318 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4725
Practice Address - Country:US
Practice Address - Phone:847-475-4960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011247111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL217164Medicare PIN