Provider Demographics
NPI:1760665558
Name:STACY A PHELPS LTD
Entity Type:Organization
Organization Name:STACY A PHELPS LTD
Other - Org Name:PHELPS CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-636-5555
Mailing Address - Street 1:5155 W 111TH ST
Mailing Address - Street 2:
Mailing Address - City:ALSIP
Mailing Address - State:IL
Mailing Address - Zip Code:60803-6021
Mailing Address - Country:US
Mailing Address - Phone:708-636-5555
Mailing Address - Fax:
Practice Address - Street 1:5155 W 111TH ST
Practice Address - Street 2:
Practice Address - City:ALSIP
Practice Address - State:IL
Practice Address - Zip Code:60803-6021
Practice Address - Country:US
Practice Address - Phone:708-636-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILV10411Medicare PIN