Basic Information
| Provider Information | |||||||||
| NPI: | 1659461309 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRESTWOOD CHIROPRACTIC AND REHAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103B SOUTHPOINTE | ||||||||
| Address2: | |||||||||
| City: | EDWARDSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620253651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186929640 | ||||||||
| FaxNumber: | 6186929643 | ||||||||
| Practice Location | |||||||||
| Address1: | 13657 CICERO AVE | ||||||||
| Address2: | |||||||||
| City: | CRESTWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604451936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083962500 | ||||||||
| FaxNumber: | 7083968605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 07/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | VAUGHT | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7083962500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.