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NPI Code Detail

MEDICARE: MARQUE MEDICOS ARCHER, LLC

MEDICARE: MARQUE MEDICOS ARCHER, 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
1111N00000XChiropractor038008088IL

General Provider Information

NPI Number : 1366681025
Entity Type Code : Organization
Provider Name (Legal Business Name) : MARQUE MEDICOS ARCHER, LLC
Provider Business Mailing Address
First Line : 4176 W MONTROSE AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60641-2161
Country : US
Telephone Number : 773-283-3131
Fax Number : 773-283-3610
Provider Business Practice Location Address
First Line : 4195 S ARCHER AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60632-1849
Country : US
Telephone Number : 773-283-3131
Fax Number : 773-283-3610
Authorized Official
Title or Position : MANAGER
Name : DR. DERRICK D. WALLERY
Credential : D.C.
Telephone Number : 773-283-3131
Provider Enumeration Date : 02/19/2009
Last Update Date : 02/19/2009

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Directions to “MARQUE MEDICOS ARCHER, LLC ” Practice Location

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