Healthcare Provider Details

I. General information

NPI: 1346495512
Provider Name (Legal Business Name): BIOBLU, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9229 S 78TH AVE
HICKORY HILLS IL
60457-2133
US

IV. Provider business mailing address

9229 S 78TH AVE
HICKORY HILLS IL
60457-2133
US

V. Phone/Fax

Practice location:
  • Phone: 866-288-3822
  • Fax:
Mailing address:
  • Phone: 866-288-3822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038011278
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number038011278
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number038011143
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number038011278
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code111NT0100X
TaxonomyThermography Chiropractor
License Number038011278
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code111NT0100X
TaxonomyThermography Chiropractor
License Number038011143
License Number StateIL

VIII. Authorized Official

Name: DR. RYAN DANIEL NOVAK
Title or Position: ADVISORY PHYSICIAN
Credential: D.C.
Phone: 866-288-3822