MEDICARE: CHIRO ONE WELLNESS CENTER OF EAST HYDE PARK 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	111N00000X	Chiropractor	038009501	IL

General Provider Information

NPI Number	:	1053750224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIRO ONE WELLNESS CENTER OF EAST HYDE PARK LLC

Provider Business Mailing Address
First Line	:	2625 BUTTERFIELD RD
Second Line	:	STE 301N
City	:	OAK BROOK
State	:	IL
Zip	:	60523-1234
Country	:	US
Telephone Number	:	630-468-1824
Fax Number	:	630-701-1007

Provider Business Practice Location Address
First Line	:	1634 E 53RD ST
Second Line	:	STE A
City	:	CHICAGO
State	:	IL
Zip	:	60615-4384
Country	:	US
Telephone Number	:	630-468-1824
Fax Number	:	630-701-1007

Authorized Official
Title or Position	:	COO
Name	:	SAM WANG
Credential	:
Telephone Number	:	630-468-1824

Provider Enumeration Date	:	06/20/2013
Last Update Date	:	06/20/2013

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