Healthcare Provider Details

I. General information

NPI: 1760788046
Provider Name (Legal Business Name): CLINICA SU RED ELGIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2011
Last Update Date: 02/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S MCLEAN BLVD STE N
ELGIN IL
60123-1023
US

IV. Provider business mailing address

300 S MCLEAN BLVD STE N
ELGIN IL
60123-1023
US

V. Phone/Fax

Practice location:
  • Phone: 847-697-1234
  • Fax: 847-697-8205
Mailing address:
  • Phone: 847-697-1234
  • Fax: 847-697-8205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038010270
License Number StateIL

VIII. Authorized Official

Name: LYNNETTE R MCROY
Title or Position: BILLING COORDINATOR
Credential:
Phone: 773-767-3822