Provider Demographics
NPI:1568501765
Name:EVERGREEN PARK CHIROPRACTIC CENTER INC
Entity Type:Organization
Organization Name:EVERGREEN PARK CHIROPRACTIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:H
Authorized Official - Last Name:WOJCIECHOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-424-4353
Mailing Address - Street 1:9256 S KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-1608
Mailing Address - Country:US
Mailing Address - Phone:708-424-4353
Mailing Address - Fax:708-424-4396
Practice Address - Street 1:9256 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-1608
Practice Address - Country:US
Practice Address - Phone:708-424-4353
Practice Address - Fax:708-424-4396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38-3468111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL445750Medicare ID - Type Unspecified