Provider Demographics
NPI:1780653071
Name:TENNANT, GARY D (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:D
Last Name:TENNANT
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 1:386 FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-2005
Mailing Address - Country:US
Mailing Address - Phone:708-481-1715
Mailing Address - Fax:708-481-8915
Practice Address - Street 1:386 FOREST BLVD
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2005
Practice Address - Country:US
Practice Address - Phone:708-481-1715
Practice Address - Fax:708-481-8915
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-005464111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL350056091OtherRR MEDICARE
IL1622660OtherBCBSIL
ILK47705Medicare PIN
IL350056091OtherRR MEDICARE