Provider Demographics
NPI:1518010545
Name:ITASCA HEALTH & CHIROPRACTIC LTD.
Entity Type:Organization
Organization Name:ITASCA HEALTH & CHIROPRACTIC LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-250-9200
Mailing Address - Street 1:1131 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-1442
Mailing Address - Country:US
Mailing Address - Phone:630-250-9200
Mailing Address - Fax:
Practice Address - Street 1:1131 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:ITASCA
Practice Address - State:IL
Practice Address - Zip Code:60143-1442
Practice Address - Country:US
Practice Address - Phone:630-250-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-21
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008856111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02227528OtherBLUE CROSS BLUE SHIELD
ILU80310Medicare UPIN
IL583070Medicare ID - Type Unspecified