Provider Demographics
NPI:1003034315
Name:VANFOSSEN CHIROPRACTIC PC
Entity Type:Organization
Organization Name:VANFOSSEN CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:VANFOSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-439-2954
Mailing Address - Street 1:55 TURNER AVE
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 TURNER AVE
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3930
Practice Address - Country:US
Practice Address - Phone:847-439-2954
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1630228OtherBLUE CROSS
IL1630228OtherBLUE CROSS