Provider Demographics
NPI:1407211832
Name:BARTLETT CHIROPRACTIC CLINIC, SC
Entity Type:Organization
Organization Name:BARTLETT CHIROPRACTIC CLINIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:RICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-795-7497
Mailing Address - Street 1:314 W ROLLINS RD
Mailing Address - Street 2:STE B
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-1204
Mailing Address - Country:US
Mailing Address - Phone:847-546-4220
Mailing Address - Fax:847-546-4262
Practice Address - Street 1:314 W ROLLINS RD
Practice Address - Street 2:STE B
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-1204
Practice Address - Country:US
Practice Address - Phone:847-546-4220
Practice Address - Fax:847-546-4262
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BARTLETT CHIROPRACTIC CLINIC, SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010561111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty