Healthcare Provider Details

I. General information

NPI: 1073549556
Provider Name (Legal Business Name): KEITH A KRETSCHMAR D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 05/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 NORTHWEST HWY SUITE 104
FOX RIVER GROVE IL
60021-1925
US

IV. Provider business mailing address

338 CARL SANDS DR
CARY IL
60013-3112
US

V. Phone/Fax

Practice location:
  • Phone: 815-451-8331
  • Fax:
Mailing address:
  • Phone: 815-451-8331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038005142
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: