MEDICARE: DR. ITASCA L WAITERS D.C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor		IL

General Provider Information

NPI Number	:	1558476812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ITASCA L WAITERS D.C

Provider Business Mailing Address
First Line	:	1604 SIBLEY BLVD
Second Line	:
City	:	CALUMET CITY
State	:	IL
Zip	:	60409-2231
Country	:	US
Telephone Number	:	708-323-7691
Fax Number	:	708-753-6214

Provider Business Practice Location Address
First Line	:	1604 SIBLEY BLVD
Second Line	:
City	:	CALUMET CITY
State	:	IL
Zip	:	60409-2231
Country	:	US
Telephone Number	:	708-323-7691
Fax Number	:	708-753-6214

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	07/08/2007

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