Healthcare Provider Details

I. General information

NPI: 1891764098
Provider Name (Legal Business Name): MIGUEL A JIMENEZ D.C., S.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 03/30/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2548 S. BLUE ISLAND AVE
CHICAGO IL
60608
US

IV. Provider business mailing address

PO BOX 8373
CHICAGO IL
60608-0373
US

V. Phone/Fax

Practice location:
  • Phone: 773-954-4438
  • Fax: 773-823-1746
Mailing address:
  • Phone: 773-954-4438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number238000485
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038-009097
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: