Provider Demographics
NPI:1821370586
Name:SOUTHWEST SPINE & ORTHO REHABILITATION
Entity Type:Organization
Organization Name:SOUTHWEST SPINE & ORTHO REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DZIELAWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-417-5777
Mailing Address - Street 1:2400 GLENWOOD AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5498
Mailing Address - Country:US
Mailing Address - Phone:815-417-5777
Mailing Address - Fax:
Practice Address - Street 1:2400 GLENWOOD AVE STE 220
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5498
Practice Address - Country:US
Practice Address - Phone:815-417-5777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty