Healthcare Provider Details

I. General information

NPI: 1013176577
Provider Name (Legal Business Name): CHIROSOURCE OF PALOS HEIGHTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12717 S RIDGELAND AVE
PALOS HEIGHTS IL
60463-2242
US

IV. Provider business mailing address

12717 S RIDGELAND AVE
PALOS HEIGHTS IL
60463-2242
US

V. Phone/Fax

Practice location:
  • Phone: 708-371-6114
  • Fax: 708-371-0816
Mailing address:
  • Phone: 708-371-6114
  • Fax: 708-371-0816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038-008221
License Number StateIL

VIII. Authorized Official

Name: DR. RICH SHEPPARD
Title or Position: PRESIDENT
Credential: DC
Phone: 708-371-6114