Healthcare Provider Details

I. General information

NPI: 1134420011
Provider Name (Legal Business Name): BANNOCKBURN CHIROPRACTIC & SPORTS INJURY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2010
Last Update Date: 04/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 WAUKEGAN RD 100
BANNOCKBURN IL
60015-1836
US

IV. Provider business mailing address

2101 WAUKEGAN RD 100
BANNOCKBURN IL
60015-1836
US

V. Phone/Fax

Practice location:
  • Phone: 847-236-1194
  • Fax: 847-236-1195
Mailing address:
  • Phone: 847-236-1194
  • Fax: 847-236-1195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.007835
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: MR. STUART EVAN YOSS
Title or Position: PRESIDENT/OWNER
Credential: DC
Phone: 847-236-1194