Provider Demographics
NPI:1730777905
Name:TRIO CHIROPRACTIC AND WELLNESS CENTER SC
Entity type:Organization
Organization Name:TRIO CHIROPRACTIC AND WELLNESS CENTER SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PETRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-914-4445
Mailing Address - Street 1:17516 E CARRIAGEWAY DR STE B
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-2079
Mailing Address - Country:US
Mailing Address - Phone:708-914-4445
Mailing Address - Fax:708-260-6699
Practice Address - Street 1:17516 E CARRIAGEWAY DR STE B
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2079
Practice Address - Country:US
Practice Address - Phone:708-914-4445
Practice Address - Fax:708-914-4393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-04
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILJ25066071669Medicaid