Provider Demographics
NPI:1629275821
Name:ADVANCED NATURAL HEALTH
Entity Type:Organization
Organization Name:ADVANCED NATURAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SITSADAPHONE
Authorized Official - Middle Name:PENG
Authorized Official - Last Name:PHETCHAMPHONE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-833-3799
Mailing Address - Street 1:PO BOX 270345
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-0345
Mailing Address - Country:US
Mailing Address - Phone:414-529-4180
Mailing Address - Fax:414-858-9082
Practice Address - Street 1:17 W 300 22 ST
Practice Address - Street 2:SUITE 460
Practice Address - City:OAKBROOK TERRACE
Practice Address - State:IL
Practice Address - Zip Code:60181
Practice Address - Country:US
Practice Address - Phone:630-833-3799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Not Answered111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherFEDERAL EIN