Provider Demographics
NPI:1356824601
Name:EVANSTON SPINE AND REHAB P.C.
Entity Type:Organization
Organization Name:EVANSTON SPINE AND REHAB P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DC, FACO
Authorized Official - Phone:773-425-8333
Mailing Address - Street 1:817 CHICAGO AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2353
Mailing Address - Country:US
Mailing Address - Phone:773-425-8333
Mailing Address - Fax:
Practice Address - Street 1:1325 HOWARD ST STE 309
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3788
Practice Address - Country:US
Practice Address - Phone:773-425-8333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-12
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty