Provider Demographics
NPI:1558476812
Name:WAITERS, ITASCA L (DC)
Entity Type:Individual
Prefix:DR
First Name:ITASCA
Middle Name:L
Last Name:WAITERS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 SIBLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-2231
Mailing Address - Country:US
Mailing Address - Phone:708-323-7691
Mailing Address - Fax:708-753-6214
Practice Address - Street 1:1604 SIBLEY BLVD
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-2231
Practice Address - Country:US
Practice Address - Phone:708-323-7691
Practice Address - Fax:708-753-6214
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor