Provider Demographics
NPI:1497067433
Name:GUNDERSON, RHETT CHARLES (DC)
Entity Type:Individual
Prefix:
First Name:RHETT
Middle Name:CHARLES
Last Name:GUNDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 S BLACKHAWK BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61072-2908
Mailing Address - Country:US
Mailing Address - Phone:815-624-2669
Mailing Address - Fax:
Practice Address - Street 1:506 S BLACKHAWK BLVD
Practice Address - Street 2:
Practice Address - City:ROCKTON
Practice Address - State:IL
Practice Address - Zip Code:61072-2908
Practice Address - Country:US
Practice Address - Phone:815-624-2669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011727111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor