Provider Demographics
NPI:1629539291
Name:SOUTHPORT GRACE CHIROPRACTIC AND WELLNESS LLC
Entity Type:Organization
Organization Name:SOUTHPORT GRACE CHIROPRACTIC AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:OLDING
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:419-628-4003
Mailing Address - Street 1:1209 W GRACE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2805
Mailing Address - Country:US
Mailing Address - Phone:772-525-2225
Mailing Address - Fax:
Practice Address - Street 1:1209 W GRACE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2805
Practice Address - Country:US
Practice Address - Phone:772-525-2225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-27
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty