MEDICARE: JEREMY BONSOL,LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center		IL

General Provider Information

NPI Number	:	1013210269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEREMY BONSOL,LLC

Provider Business Mailing Address
First Line	:	3514 N SOUTHPORT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1436
Country	:	US
Telephone Number	:	773-248-2544
Fax Number	:	505-213-3515

Provider Business Practice Location Address
First Line	:	3514 N SOUTHPORT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1436
Country	:	US
Telephone Number	:	773-248-2544
Fax Number	:	505-213-3515

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JEREMY BONSOL
Credential	:	DC
Telephone Number	:	773-663-5351

Provider Enumeration Date	:	12/09/2010
Last Update Date	:	12/09/2010

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