Healthcare Provider Details

I. General information

NPI: 1396575502
Provider Name (Legal Business Name): CONNOR FAGAN DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2736 MAPLE AVE
DOWNERS GROVE IL
60515-4201
US

IV. Provider business mailing address

2736 MAPLE AVE
DOWNERS GROVE IL
60515-4201
US

V. Phone/Fax

Practice location:
  • Phone: 630-963-0080
  • Fax: 630-963-0341
Mailing address:
  • Phone: 630-963-0080
  • Fax: 630-963-0341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.014167
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: