Provider Demographics
NPI:1659461309
Name:CRESTWOOD CHIROPRACTIC AND REHAB
Entity Type:Organization
Organization Name:CRESTWOOD CHIROPRACTIC AND REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-396-2500
Mailing Address - Street 1:103B SOUTHPOINTE
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3651
Mailing Address - Country:US
Mailing Address - Phone:618-692-9640
Mailing Address - Fax:618-692-9643
Practice Address - Street 1:13657 CICERO AVE
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60445-1936
Practice Address - Country:US
Practice Address - Phone:708-396-2500
Practice Address - Fax:708-396-8605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty