Provider Demographics
NPI:1073726626
Name:GLESENER CHIROPRACTIC CENTER PC
Entity Type:Organization
Organization Name:GLESENER CHIROPRACTIC CENTER PC
Other - Org Name:FOX VALLEY CHIROPRACTIC PHYSICIANS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:GLESENER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-747-8844
Mailing Address - Street 1:1750 E MAIN ST STE 60
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2363
Mailing Address - Country:US
Mailing Address - Phone:630-377-8844
Mailing Address - Fax:630-377-8404
Practice Address - Street 1:1750 E MAIN ST
Practice Address - Street 2:SUITE 60
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2363
Practice Address - Country:US
Practice Address - Phone:630-377-8844
Practice Address - Fax:630-377-8404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-006085111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04532055OtherBLUE CROSS BLUE SHIELD
ILT39014Medicare UPIN
ILK13653Medicare ID - Type Unspecified