Provider Demographics
NPI:1659760239
Name:EDELEN, RENEE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:EDELEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 ROZIER ST
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4249
Mailing Address - Country:US
Mailing Address - Phone:618-363-1591
Mailing Address - Fax:
Practice Address - Street 1:638 ROZIER ST
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4249
Practice Address - Country:US
Practice Address - Phone:618-363-1591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-20
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012760111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor