Healthcare Provider Details

I. General information

NPI: 1033499488
Provider Name (Legal Business Name): CHIRO ONE WELLNESS CENTER METRO OF OLD IRVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4030 N. CICERO
CHICAGO IL
60461
US

IV. Provider business mailing address

2625 BUTTERFIELD RD STE 301N
OAK BROOK IL
60523-1234
US

V. Phone/Fax

Practice location:
  • Phone: 773-557-7766
  • Fax: 773-557-7767
Mailing address:
  • Phone: 630-320-6400
  • Fax: 630-320-6489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SAM WANG
Title or Position: COO
Credential:
Phone: 630-468-1824