Healthcare Provider Details

I. General information

NPI: 1629455977
Provider Name (Legal Business Name): FAMILY TREE CHIROPRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 RENAISSANCE DR SUITE 120
PARK RIDGE IL
60068-1356
US

IV. Provider business mailing address

1440 RENAISSANCE DR SUITE 120
PARK RIDGE IL
60068-1356
US

V. Phone/Fax

Practice location:
  • Phone: 847-403-1101
  • Fax:
Mailing address:
  • Phone: 847-403-1101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038012789
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number038012789
License Number StateIL

VIII. Authorized Official

Name: DR. WHITNEY LEIGH FANDEL
Title or Position: OWNER
Credential: D.C.
Phone: 847-403-1101