Provider Demographics
NPI:1164649976
Name:EDWARDS CHIROPRACTIC CLINIC P.C
Entity Type:Organization
Organization Name:EDWARDS CHIROPRACTIC CLINIC P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARTH
Authorized Official - Middle Name:L
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD,DC,MHS,DACBN,CCN
Authorized Official - Phone:708-748-5600
Mailing Address - Street 1:1824 HEATHER HILL CRES
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22111 GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1249
Practice Address - Country:US
Practice Address - Phone:708-747-5600
Practice Address - Fax:708-748-5635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1013922673OtherNPI INDIVIDUAL
IL1645747OtherBCBS PROVIDER
IL723620Medicare PIN
IL1645747OtherBCBS PROVIDER