Healthcare Provider Details

I. General information

NPI: 1235120825
Provider Name (Legal Business Name): ANTIOCH FAMILY CHIROPRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 11/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 VICTORIA ST
ANTIOCH IL
60002-1519
US

IV. Provider business mailing address

960 VICTORIA ST
ANTIOCH IL
60002-1519
US

V. Phone/Fax

Practice location:
  • Phone: 847-838-0688
  • Fax: 847-838-0690
Mailing address:
  • Phone: 847-838-0688
  • Fax: 847-838-0690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. JOAN MARIE JOHNSON
Title or Position: CHIROPRACTOR/PRESIDENT
Credential: D.C.
Phone: 847-838-0688