Healthcare Provider Details

I. General information

NPI: 1548385933
Provider Name (Legal Business Name): GONZAGA LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 E CHICAGO ST
ELGIN IL
60120-6502
US

IV. Provider business mailing address

221 E CHICAGO ST
ELGIN IL
60120-6502
US

V. Phone/Fax

Practice location:
  • Phone: 847-468-6012
  • Fax: 847-468-6013
Mailing address:
  • Phone: 847-468-6012
  • Fax: 847-468-6013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038-008895
License Number StateIL

VIII. Authorized Official

Name: DR. JAENA STANLEY-GONZAGA
Title or Position: PRESIDENT
Credential: D.C.
Phone: 847-468-6012