Healthcare Provider Details

I. General information

NPI: 1750506077
Provider Name (Legal Business Name): NECK TO BACK LAKE COUNTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 WAUKEGAN RD SUITE 100
LAKE BLUFF IL
60044-3009
US

IV. Provider business mailing address

7177 CRIMSON RIDGE DR SUITE 14
ROCKFORD IL
61107-6208
US

V. Phone/Fax

Practice location:
  • Phone: 847-283-0950
  • Fax: 847-283-0951
Mailing address:
  • Phone: 815-227-9900
  • Fax: 815-227-9805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038010204
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036104819
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number036-104819
License Number StateIL

VIII. Authorized Official

Name: DR. DAVID SERAFINI
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 847-283-0950