Healthcare Provider Details

I. General information

NPI: 1811430481
Provider Name (Legal Business Name): MATEUSZ JAN CICHOWICZ D.C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8612 S 85TH CT
HICKORY HILLS IL
60457-1012
US

IV. Provider business mailing address

8612 S 85TH CT
HICKORY HILLS IL
60457-1012
US

V. Phone/Fax

Practice location:
  • Phone: 708-407-0544
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number038.013027
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number038.013027
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: