MEDICARE: CHIROSOURCE OF PALOS HEIGHTS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	038-008221	IL

General Provider Information

NPI Number	:	1013176577
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIROSOURCE OF PALOS HEIGHTS

Provider Business Mailing Address
First Line	:	12717 S RIDGELAND AVE
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-2242
Country	:	US
Telephone Number	:	708-371-6114
Fax Number	:	708-371-0816

Provider Business Practice Location Address
First Line	:	12717 S RIDGELAND AVE
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-2242
Country	:	US
Telephone Number	:	708-371-6114
Fax Number	:	708-371-0816

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICH SHEPPARD
Credential	:	DC
Telephone Number	:	708-371-6114

Provider Enumeration Date	:	06/09/2008
Last Update Date	:	06/09/2008

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