Healthcare Provider Details

I. General information

NPI: 1700845047
Provider Name (Legal Business Name): JOSEPH JOHN ETHEN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

662 VERNON AVE
GLENCOE IL
60022-1694
US

IV. Provider business mailing address

662 VERNON AVE
GLENCOE IL
60022-1694
US

V. Phone/Fax

Practice location:
  • Phone: 847-835-4700
  • Fax: 847-835-8408
Mailing address:
  • Phone: 847-835-4700
  • Fax: 847-835-8408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.011678
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: