Provider Demographics
NPI:1932388519
Name:DNA HEALTH SERVICES
Entity Type:Organization
Organization Name:DNA HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BROOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-986-4411
Mailing Address - Street 1:1820 WINDSOR RD
Mailing Address - Street 2:SUIT A
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4271
Mailing Address - Country:US
Mailing Address - Phone:815-986-4411
Mailing Address - Fax:
Practice Address - Street 1:1820 WINDSOR RD
Practice Address - Street 2:SUIT A
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4271
Practice Address - Country:US
Practice Address - Phone:815-986-4411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042619163111N00000X, 111NS0005X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU73389Medicare UPIN
IL528320Medicare PIN