Provider Demographics
NPI:1134556822
Name:CRYSTAL LAKE NATURAL HEALTH CARE
Entity type:Organization
Organization Name:CRYSTAL LAKE NATURAL HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:CWIKLA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:312-451-4961
Mailing Address - Street 1:807 POINTE DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-8024
Mailing Address - Country:US
Mailing Address - Phone:312-451-4961
Mailing Address - Fax:
Practice Address - Street 1:30B N WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:312-451-4961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011708111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty