Provider Demographics
NPI:1629322300
Name:NATURAL HEALING OF WAUCONDA
Entity Type:Organization
Organization Name:NATURAL HEALING OF WAUCONDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-469-8260
Mailing Address - Street 1:115 E LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-1929
Mailing Address - Country:US
Mailing Address - Phone:847-477-6465
Mailing Address - Fax:
Practice Address - Street 1:115 E LIBERTY ST
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-1929
Practice Address - Country:US
Practice Address - Phone:847-477-6465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU59281Medicare UPIN