Basic Information
| Provider Information | |||||||||
| NPI: | 1629270954 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH ON EARTH WELLNESS CENTERS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CRESTWOOD CHIROPRACTIC AND REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11933 S PULASKI RD STE C | ||||||||
| Address2: | |||||||||
| City: | ALSIP | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608031100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147045959 | ||||||||
| FaxNumber: | 7083968605 | ||||||||
| Practice Location | |||||||||
| Address1: | 13657 S. CICERO AVE | ||||||||
| Address2: | |||||||||
| City: | CRESTWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604451936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083962500 | ||||||||
| FaxNumber: | 7083968605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 06/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VAUGHT | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7083962500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DC | ||||||||
| NPICertificationDate: | 06/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 038010171 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.