Provider Demographics
NPI:1366654501
Name:SPINE INSTITUTE OF WAUKEGAN
Entity Type:Organization
Organization Name:SPINE INSTITUTE OF WAUKEGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:G
Authorized Official - Last Name:WORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-775-0800
Mailing Address - Street 1:2634 GRAND AVE SUITE 100
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-2458
Mailing Address - Country:US
Mailing Address - Phone:847-775-0800
Mailing Address - Fax:847-775-0888
Practice Address - Street 1:2634 GRAND AVE SUITE 100
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2458
Practice Address - Country:US
Practice Address - Phone:847-775-0800
Practice Address - Fax:847-775-0888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty