Provider Demographics
NPI:1790970390
Name:DAVENPORT CHIROPRACTIC WELLNESS CENTER PC
Entity Type:Organization
Organization Name:DAVENPORT CHIROPRACTIC WELLNESS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-368-3200
Mailing Address - Street 1:3350 W SALT CREEK LN
Mailing Address - Street 2:SUITE 109
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-5023
Mailing Address - Country:US
Mailing Address - Phone:847-368-3200
Mailing Address - Fax:847-368-7808
Practice Address - Street 1:3350 W SALT CREEK LN
Practice Address - Street 2:SUITE 109
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-5023
Practice Address - Country:US
Practice Address - Phone:847-368-3200
Practice Address - Fax:847-368-7808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU57627Medicare UPIN