Provider Demographics
NPI:1720044571
Name:WILLARETH, GLENN C (DC)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:C
Last Name:WILLARETH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1891
Mailing Address - Country:US
Mailing Address - Phone:815-942-5350
Mailing Address - Fax:815-942-5414
Practice Address - Street 1:118 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1891
Practice Address - Country:US
Practice Address - Phone:815-942-5350
Practice Address - Fax:815-942-5414
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0380003315111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3282001OtherBLUE CROSS/BLUE SHIELD
IL259800Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
ILT35708Medicare UPIN