Provider Demographics
NPI:1417957184
Name:HOLLETT, ROBERT W (DC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:HOLLETT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:BOB
Other - Middle Name:W
Other - Last Name:HOLLETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:61 POLARIS DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-5606
Mailing Address - Country:US
Mailing Address - Phone:847-658-6500
Mailing Address - Fax:
Practice Address - Street 1:61 POLARIS DR
Practice Address - Street 2:SUITE 1
Practice Address - City:LAKE IN THE HILLS
Practice Address - State:IL
Practice Address - Zip Code:60156-5606
Practice Address - Country:US
Practice Address - Phone:847-658-6500
Practice Address - Fax:224-333-0242
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009906111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK21570Medicare PIN
ILV06845Medicare UPIN