Provider Demographics
NPI:1538438577
Name:HANSEN, RICHARD E JR (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:E
Last Name:HANSEN
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 18TH AVE
Mailing Address - Street 2:SUITE 2 SS
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-3668
Mailing Address - Country:US
Mailing Address - Phone:309-793-6688
Mailing Address - Fax:
Practice Address - Street 1:2100 18TH AVE
Practice Address - Street 2:SUITE 2 SS
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-3668
Practice Address - Country:US
Practice Address - Phone:309-793-6688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.004795111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor