Healthcare Provider Details

I. General information

NPI: 1740510593
Provider Name (Legal Business Name): HOMER CHIROPRACTIC CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2009
Last Update Date: 12/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12261 W 159TH ST
HOMER GLEN IL
60491-7847
US

IV. Provider business mailing address

12261 W 159TH ST
HOMER GLEN IL
60491-7847
US

V. Phone/Fax

Practice location:
  • Phone: 708-301-2255
  • Fax: 708-301-2631
Mailing address:
  • Phone: 708-301-2255
  • Fax: 708-301-2631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number038004287
License Number StateIL

VIII. Authorized Official

Name: DR. HELEN E OWENS
Title or Position: MANAGER
Credential: DPT
Phone: 708-301-2255