Provider Demographics
NPI:1750359980
Name:ILLINGWORTH, ROBERT A (DC)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:ILLINGWORTH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 KINGS CT
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-1926
Mailing Address - Country:US
Mailing Address - Phone:563-355-6611
Mailing Address - Fax:
Practice Address - Street 1:1000 BRADY ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-5214
Practice Address - Country:US
Practice Address - Phone:563-884-5801
Practice Address - Fax:563-884-5731
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05666111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U52166Medicare UPIN