Healthcare Provider Details

I. General information

NPI: 1376564807
Provider Name (Legal Business Name): PAUL MATTHEW MIKULSKI D.C., C.C.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5929 N MOBILE AVE
CHICAGO IL
60646-5330
US

IV. Provider business mailing address

5929 N MOBILE AVE
CHICAGO IL
60646-5330
US

V. Phone/Fax

Practice location:
  • Phone: 773-573-6348
  • Fax:
Mailing address:
  • Phone: 773-573-6348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: