Healthcare Provider Details

I. General information

NPI: 1700132891
Provider Name (Legal Business Name): BARTLETT CHIROPRACTIC CLINIC, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2012
Last Update Date: 07/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 S OAK AVE
BARTLETT IL
60103-6620
US

IV. Provider business mailing address

138 S OAK AVE
BARTLETT IL
60103-6620
US

V. Phone/Fax

Practice location:
  • Phone: 630-830-1500
  • Fax: 630-830-2513
Mailing address:
  • Phone: 630-830-1500
  • Fax: 630-830-2513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038010561
License Number StateIL

VIII. Authorized Official

Name: MR. KEITH CHARLES RICHARD
Title or Position: PRESIDENT
Credential: DC
Phone: 630-830-1500