Provider Demographics
NPI:1457530628
Name:ETHEN CHIROPRACTIC & WELLNESS, SC
Entity Type:Organization
Organization Name:ETHEN CHIROPRACTIC & WELLNESS, SC
Other - Org Name:LAKEFRONT CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ETHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-835-4700
Mailing Address - Street 1:630 VERNON AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:GLENCOE
Mailing Address - State:IL
Mailing Address - Zip Code:60022
Mailing Address - Country:US
Mailing Address - Phone:847-835-4700
Mailing Address - Fax:847-835-8408
Practice Address - Street 1:630 VERNON AVE
Practice Address - Street 2:SUITE F
Practice Address - City:GLENCOE
Practice Address - State:IL
Practice Address - Zip Code:60022
Practice Address - Country:US
Practice Address - Phone:847-835-4700
Practice Address - Fax:847-835-8408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9358811OtherMEDICARE GROUP NUMBER