Provider Demographics
NPI:1114156916
Name:COMPLETELY CHIROPRACTIC, LTD.
Entity Type:Organization
Organization Name:COMPLETELY CHIROPRACTIC, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-448-3818
Mailing Address - Street 1:6852 W 111TH STREET
Mailing Address - Street 2:
Mailing Address - City:WORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60482
Mailing Address - Country:US
Mailing Address - Phone:708-448-3818
Mailing Address - Fax:708-448-3804
Practice Address - Street 1:6852 W 111TH STREET
Practice Address - Street 2:
Practice Address - City:WORTH
Practice Address - State:IL
Practice Address - Zip Code:60482
Practice Address - Country:US
Practice Address - Phone:708-448-3818
Practice Address - Fax:708-448-3804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-14
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008775111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL570260Medicare UPIN