Provider Demographics
NPI:1245399054
Name:RICHARD, KEITH CHARLES (DC)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:CHARLES
Last Name:RICHARD
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 1:138 S OAK AVE
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-6620
Mailing Address - Country:US
Mailing Address - Phone:630-830-1500
Mailing Address - Fax:630-830-2513
Practice Address - Street 1:138 S OAK AVE
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-6620
Practice Address - Country:US
Practice Address - Phone:630-830-1500
Practice Address - Fax:630-830-2513
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7396111N00000X
IL038010561111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3817636Medicaid
55689OtherBCBS
FLAD239OtherMEDICARE GROUP ID
FL55689XMedicare PIN
55689OtherBCBS