Provider Demographics
NPI:1669653770
Name:HEALTHSOURCE OF DEER PARK
Entity Type:Organization
Organization Name:HEALTHSOURCE OF DEER PARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:J.
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:REFFELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-726-0044
Mailing Address - Street 1:20876 N RAND RD
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60010-3707
Mailing Address - Country:US
Mailing Address - Phone:847-726-0044
Mailing Address - Fax:
Practice Address - Street 1:20876 N RAND RD
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:IL
Practice Address - Zip Code:60010-3707
Practice Address - Country:US
Practice Address - Phone:847-726-0044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2014-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007087111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL490-50-20OtherBLUECROSS BLUESHIELD
IL999-950Medicare PIN
ILU45709Medicare UPIN