Provider Demographics
NPI:1013210152
Name:WILLARETH CLINIC OF CHIROPRACTIC LTD.
Entity Type:Organization
Organization Name:WILLARETH CLINIC OF CHIROPRACTIC LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILLARETH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-942-5350
Mailing Address - Street 1:118 E. JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1891
Mailing Address - Country:US
Mailing Address - Phone:815-942-5350
Mailing Address - Fax:815-942-5414
Practice Address - Street 1:118 E. JACKSON ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1891
Practice Address - Country:US
Practice Address - Phone:815-942-5350
Practice Address - Fax:815-942-5414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILDC38-3315111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty