1154816775 NPI number — GARRETT EZELL DC PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154816775 NPI number — GARRETT EZELL DC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARRETT EZELL DC PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154816775
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6101 W WARWICK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60634-2557
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-451-2707
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7323 NORTHGATE WAY UNIT 9
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOWNERS GROVE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60516-4058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-451-2707
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EZELL
Authorized Official First Name:
GARRETT
Authorized Official Middle Name:
PRESTON
Authorized Official Title or Position:
CHIROPRACTIC PHYSICIAN
Authorized Official Telephone Number:
312-451-2707

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)