Healthcare Provider Details

I. General information

NPI: 1710436043
Provider Name (Legal Business Name): MJMNMT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1192 WALTER ST STE C
LEMONT IL
60439-2905
US

IV. Provider business mailing address

1192 WALTER ST STE C
LEMONT IL
60439-2905
US

V. Phone/Fax

Practice location:
  • Phone: 630-257-0550
  • Fax: 630-257-0555
Mailing address:
  • Phone: 630-257-0550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number038.012507
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number038.005323
License Number StateIL

VIII. Authorized Official

Name: DR. MATTHEW JACOB IMBER
Title or Position: OWNER
Credential: D.C., DACNB
Phone: 630-257-0550