Healthcare Provider Details

I. General information

NPI: 1508149691
Provider Name (Legal Business Name): KENNETH MARK SISTINO D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2011
Last Update Date: 09/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2229 W CHICAGO AVE
CHICAGO IL
60622-4828
US

IV. Provider business mailing address

2229 W CHICAGO AVE
CHICAGO IL
60622-4828
US

V. Phone/Fax

Practice location:
  • Phone: 773-862-4500
  • Fax: 773-862-4517
Mailing address:
  • Phone: 773-862-4500
  • Fax: 773-862-4517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038-006195
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: