MEDICARE: CROSSTOWN CHIROPRACTIC 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	038.011645	IL

General Provider Information

NPI Number	:	1417313636
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSTOWN CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	3649 N KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-4513
Country	:	US
Telephone Number	:	773-961-8970
Fax Number	:	773-961-8951

Provider Business Practice Location Address
First Line	:	3649 N KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-4513
Country	:	US
Telephone Number	:	773-961-8970
Fax Number	:	773-961-8951

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL AHO
Credential	:	D.C.
Telephone Number	:	773-961-8970

Provider Enumeration Date	:	01/04/2016
Last Update Date	:	01/04/2016

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