Healthcare Provider Details

I. General information

NPI: 1194833616
Provider Name (Legal Business Name): WICKER PARK CHIROPRACTIC HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 W NORTH AVE
CHICAGO IL
60647-5659
US

IV. Provider business mailing address

2300 W NORTH AVE
CHICAGO IL
60647-5659
US

V. Phone/Fax

Practice location:
  • Phone: 773-276-7300
  • Fax: 773-276-7333
Mailing address:
  • Phone: 773-276-7300
  • Fax: 773-276-7333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON LEE SMITH
Title or Position: CHIROPRACTIC PHYSICAN
Credential: DC
Phone: 773-276-7300