Healthcare Provider Details

I. General information

NPI: 1366600017
Provider Name (Legal Business Name): NORTHWESTERN PEAK PERFORMANCE HEALTH CARE, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 09/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6139 W TOUHY AVE
CHICAGO IL
60646-1268
US

IV. Provider business mailing address

6139 W TOUHY AVE
CHICAGO IL
60646-1268
US

V. Phone/Fax

Practice location:
  • Phone: 312-440-9646
  • Fax: 773-767-3944
Mailing address:
  • Phone: 312-440-9646
  • Fax: 773-767-3944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number042619249
License Number StateIL

VIII. Authorized Official

Name: MRS. LYNN MCROY
Title or Position: BILLING COORDINATOR
Credential:
Phone: 773-767-3822