Provider Demographics
NPI:1821070525
Name:PHETCHAMPHONE, SITIHIAMPHONE (DC)
Entity Type:Individual
Prefix:DR
First Name:SITIHIAMPHONE
Middle Name:
Last Name:PHETCHAMPHONE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MISS
Other - First Name:SITIHIAMPHONE
Other - Middle Name:
Other - Last Name:PHETCHAMPHONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC, LAC
Mailing Address - Street 1:17 W. 580 BUTTERFIELD RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181
Mailing Address - Country:US
Mailing Address - Phone:630-495-1855
Mailing Address - Fax:
Practice Address - Street 1:17 W. 580 BUTTERFIELD RD
Practice Address - Street 2:SUITE J
Practice Address - City:OAKBROOK TERRACE
Practice Address - State:IL
Practice Address - Zip Code:60181
Practice Address - Country:US
Practice Address - Phone:630-495-1855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009954111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2232336OtherBCBS
IL207582Medicare PIN