Provider Demographics
NPI:1023134731
Name:INTENTIONAL HEALING CHIROPRACTIC & CENTER FOR WELL-BEING PA
Entity type:Organization
Organization Name:INTENTIONAL HEALING CHIROPRACTIC & CENTER FOR WELL-BEING PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SUKUP
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-202-2866
Mailing Address - Street 1:949 LAKE ST
Mailing Address - Street 2:UNIT F3
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1260
Mailing Address - Country:US
Mailing Address - Phone:612-202-2866
Mailing Address - Fax:
Practice Address - Street 1:949 LAKE ST
Practice Address - Street 2:UNIT F3
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1260
Practice Address - Country:US
Practice Address - Phone:612-202-2866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN808111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty