Provider Demographics
NPI:1881794469
Name:TRICHARDT, GARETH (DC)
Entity type:Individual
Prefix:
First Name:GARETH
Middle Name:
Last Name:TRICHARDT
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 1:219 ASHCROFT LN
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-8396
Mailing Address - Country:US
Mailing Address - Phone:815-302-4662
Mailing Address - Fax:815-293-3235
Practice Address - Street 1:197 W ROMEO RD
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-1564
Practice Address - Country:US
Practice Address - Phone:815-293-3233
Practice Address - Fax:815-293-3235
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008014111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038008014Medicaid
IL2222329OtherBLUE CROSS BLUE SHIELD
IL571050Medicare ID - Type Unspecified
IL2222329OtherBLUE CROSS BLUE SHIELD