MEDICARE: INETTA V NIKOGOSIAN DN

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		IL

General Provider Information

NPI Number	:	1104920818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	INETTA V NIKOGOSIAN DN

Provider Business Mailing Address
First Line	:	333 E IL ROUTE 83
Second Line	:	SUITE 106
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-4214
Country	:	US
Telephone Number	:	847-566-0003
Fax Number	:	847-566-5503

Provider Business Practice Location Address
First Line	:	333 E IL ROUTE 83
Second Line	:	SUITE 106
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-4214
Country	:	US
Telephone Number	:	847-566-0003
Fax Number	:	847-566-5503

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2006
Last Update Date	:	11/08/2007

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