Provider Demographics
NPI:1083094940
Name:EDGEBROOK CHIROPRACTIC HEALTH CENTER
Entity Type:Organization
Organization Name:EDGEBROOK CHIROPRACTIC HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:EVANA
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-436-2596
Mailing Address - Street 1:6139 W TOUHY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-1268
Mailing Address - Country:US
Mailing Address - Phone:847-436-2596
Mailing Address - Fax:847-675-8305
Practice Address - Street 1:6139 W TOUHY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-1268
Practice Address - Country:US
Practice Address - Phone:847-436-2596
Practice Address - Fax:847-675-8305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011168111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3964001Medicare PIN