MEDICARE: AXIAL SPINE & WELLNESS, 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	038012711	IL

General Provider Information

NPI Number	:	1932654084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AXIAL SPINE & WELLNESS, LLC

Provider Business Mailing Address
First Line	:	954 W WASHINGTON BLVD STE 610
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-2293
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	954 W WASHINGTON BLVD
Second Line	:	SUITE 110
City	:	CHICAGO
State	:	IL
Zip	:	60607-2224
Country	:	US
Telephone Number	:	308-227-9071
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TODD PETERSON
Credential	:	D.C.
Telephone Number	:	312-523-4392

Provider Enumeration Date	:	08/18/2016
Last Update Date	:	09/28/2020

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