Provider Demographics
NPI:1346603156
Name:EVANSTON INTEGRATIVE CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:EVANSTON INTEGRATIVE CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARNETRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-570-0970
Mailing Address - Street 1:708 CHURCH ST
Mailing Address - Street 2:STE. 228
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3875
Mailing Address - Country:US
Mailing Address - Phone:847-570-0970
Mailing Address - Fax:847-570-0972
Practice Address - Street 1:708 CHURCH ST
Practice Address - Street 2:STE. 228
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3875
Practice Address - Country:US
Practice Address - Phone:847-570-0970
Practice Address - Fax:847-570-0972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010558111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF300212187OtherMEDICARE PTAN