Provider Demographics
NPI:1245291939
Name:RONALD K WASSENAR
Entity type:Organization
Organization Name:RONALD K WASSENAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:K
Authorized Official - Last Name:WASSENAR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-562-9200
Mailing Address - Street 1:10526 W CERMAK RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5249
Mailing Address - Country:US
Mailing Address - Phone:708-562-9200
Mailing Address - Fax:708-562-9207
Practice Address - Street 1:10526 W CERMAK RD
Practice Address - Street 2:SUITE 104
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-5249
Practice Address - Country:US
Practice Address - Phone:708-562-9200
Practice Address - Fax:708-562-9207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
769657OtherCOVENTRY HEALTHCARE
IL1682731OtherBC/BS
IL5044243OtherAETNA
113554250227OtherHUMANA
769657OtherCOVENTRY HEALTHCARE
ILT38283Medicare UPIN