Provider Demographics
NPI:1871201707
Name:EDGEWATER CHIROPRACTIC LLC
Entity type:Organization
Organization Name:EDGEWATER CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:SHINAULT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-320-8801
Mailing Address - Street 1:6033 N SHERIDAN RD # CWO7S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-3003
Mailing Address - Country:US
Mailing Address - Phone:708-320-8801
Mailing Address - Fax:
Practice Address - Street 1:6033 N SHERIDAN RD # CWO7S
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-3003
Practice Address - Country:US
Practice Address - Phone:708-320-8801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty