MEDICARE: OSWEGO CHIROPRACTIC, LTD.

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	:	1790983492
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OSWEGO CHIROPRACTIC, LTD.

Provider Business Mailing Address
First Line	:	628 SALEM CIR
Second Line	:
City	:	OSWEGO
State	:	IL
Zip	:	60543-8665
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	73 W VAN BUREN ST
Second Line	:
City	:	OSWEGO
State	:	IL
Zip	:	60543-7213
Country	:	US
Telephone Number	:	630-554-3578
Fax Number	:	630-554-3792

Authorized Official
Title or Position	:	CHIROPRACTIC PHYSICIAN
Name	:	DR. SHANE WADE
Credential	:	D.C.
Telephone Number	:	630-554-3578

Provider Enumeration Date	:	07/05/2007
Last Update Date	:	07/17/2007

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