Healthcare Provider Details

I. General information

NPI: 1851713341
Provider Name (Legal Business Name): DYLON ZICCHINO LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2014
Last Update Date: 01/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1453 N TALMAN AVE APT 3
CHICAGO IL
60622-8786
US

IV. Provider business mailing address

1453 N TALMAN AVE APT 3
CHICAGO IL
60622-8786
US

V. Phone/Fax

Practice location:
  • Phone: 201-835-3098
  • Fax:
Mailing address:
  • Phone: 201-835-3098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227013837
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: