MEDICARE: REFLECTIONS OF HEALTH INTEGRATIVE CARE CENTER, 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	038011180	IL

General Provider Information

NPI Number	:	1710120647
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REFLECTIONS OF HEALTH INTEGRATIVE CARE CENTER, LLC

Provider Business Mailing Address
First Line	:	2950 W WASHINGTON BLVD
Second Line	:	MARTIN LUTHER KING JR. BOYS & GIRLS CLUB BLDG
City	:	CHICAGO
State	:	IL
Zip	:	60612-1934
Country	:	US
Telephone Number	:	773-826-9455
Fax Number	:	866-403-6309

Provider Business Practice Location Address
First Line	:	2950 W WASHINGTON BLVD
Second Line	:	MARTIN LUTHER KING JR. BOYS & GIRLS CLUB BLDG
City	:	CHICAGO
State	:	IL
Zip	:	60612-1934
Country	:	US
Telephone Number	:	773-826-9455
Fax Number	:	866-403-6309

Authorized Official
Title or Position	:	FOUNDER/CEO/ADMINISTRATIVE DIR.
Name	:	MS. THERESA ROSE STARK
Credential	:	LCMT, CPFT
Telephone Number	:	773-826-9455

Provider Enumeration Date	:	04/08/2009
Last Update Date	:	11/06/2009

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