Provider Demographics
NPI:1124214325
Name:HOMER GLEN CHIROPRACTIC CENTER, SC
Entity Type:Organization
Organization Name:HOMER GLEN CHIROPRACTIC CENTER, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:MAHOLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-302-8763
Mailing Address - Street 1:13161 W 143RD ST
Mailing Address - Street 2:SUITE 204B
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-6890
Mailing Address - Country:US
Mailing Address - Phone:708-301-9121
Mailing Address - Fax:708-301-4372
Practice Address - Street 1:13161 W 143RD ST
Practice Address - Street 2:SUITE 204B
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-6890
Practice Address - Country:US
Practice Address - Phone:708-301-9121
Practice Address - Fax:708-301-4372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty