Provider Demographics
NPI:1760853857
Name:EDWARDS CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:EDWARDS CHIROPRACTIC CLINIC
Other - Org Name:HEALTHSOURCE OF RICHTON PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARTH
Authorized Official - Middle Name:L
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DC
Authorized Official - Phone:708-748-5600
Mailing Address - Street 1:22111 GOVERNORS HWY
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1249
Mailing Address - Country:US
Mailing Address - Phone:708-748-5600
Mailing Address - Fax:708-748-5635
Practice Address - Street 1:22111 GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1249
Practice Address - Country:US
Practice Address - Phone:708-748-5600
Practice Address - Fax:708-748-5635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038005184111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF100233998OtherMEDICARE ID
ILF100233998OtherMEDICARE ID