Healthcare Provider Details

I. General information

NPI: 1326484874
Provider Name (Legal Business Name): J REVELLO CHIROPRACTIC SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2013
Last Update Date: 05/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13703 CICERO AVE
CRESTWOOD IL
60445-1824
US

IV. Provider business mailing address

13703 CICERO AVE
CRESTWOOD IL
60445-1824
US

V. Phone/Fax

Practice location:
  • Phone: 708-385-4416
  • Fax: 708-388-8825
Mailing address:
  • Phone: 708-385-4416
  • Fax: 708-388-8825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.010310
License Number StateIL

VIII. Authorized Official

Name: JOHN REVELLO
Title or Position: CHIROPRACTOR
Credential:
Phone: 708-385-4416