Healthcare Provider Details

I. General information

NPI: 1164618468
Provider Name (Legal Business Name): AZZA MUSTAFA ABUGISISA D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8550 S HARLEM AVE STE B
BRIDGEVIEW IL
60455-1775
US

IV. Provider business mailing address

8550 S HARLEM AVE STE B
BRIDGEVIEW IL
60455-1775
US

V. Phone/Fax

Practice location:
  • Phone: 708-598-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number01-05118
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.011508
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: