Provider Demographics
NPI:1114616802
Name:REIDER, KEVIN PATRICK (DC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:PATRICK
Last Name:REIDER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6178 N NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-2126
Mailing Address - Country:US
Mailing Address - Phone:773-570-6404
Mailing Address - Fax:
Practice Address - Street 1:6178 N NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-2126
Practice Address - Country:US
Practice Address - Phone:773-570-6404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013988111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor