MEDICARE: ABIDEMI CHARLES D.N.

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	172P00000X	Naprapath	181000377	IL

General Provider Information

NPI Number	:	1134566227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABIDEMI CHARLES D.N.

Provider Business Mailing Address
First Line	:	3620 N PINE GROVE AVE
Second Line	:	508
City	:	CHICAGO
State	:	IL
Zip	:	60613-4552
Country	:	US
Telephone Number	:	312-513-0553
Fax Number	:

Provider Business Practice Location Address
First Line	:	3620 N PINE GROVE AVE
Second Line	:	508
City	:	CHICAGO
State	:	IL
Zip	:	60613-4552
Country	:	US
Telephone Number	:	312-513-0553
Fax Number	:

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

Provider Enumeration Date	:	05/29/2013
Last Update Date	:	06/10/2014

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