Healthcare Provider Details

I. General information

NPI: 1508289745
Provider Name (Legal Business Name): PETER NEOFOTISTOS DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2014
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3327 VOLLMER RD STE B
FLOSSMOOR IL
60422-2091
US

IV. Provider business mailing address

3327 VOLLMER RD STE B
FLOSSMOOR IL
60422-2091
US

V. Phone/Fax

Practice location:
  • Phone: 708-999-9999
  • Fax:
Mailing address:
  • Phone: 708-243-0411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038012580
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number038012580
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number038012580
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number038012580
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: