Healthcare Provider Details

I. General information

NPI: 1003376245
Provider Name (Legal Business Name): CHICAGO ANTI AGING INSTITUTE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 03/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16622 W 159TH ST STE 500
LOCKPORT IL
60441-8015
US

IV. Provider business mailing address

16622 W 159TH ST STE 500
LOCKPORT IL
60441-8015
US

V. Phone/Fax

Practice location:
  • Phone: 815-838-7746
  • Fax: 815-838-5090
Mailing address:
  • Phone: 815-838-7746
  • Fax: 815-838-5090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LOREN DAVIS
Title or Position: PRESIDENT
Credential: DC
Phone: 708-267-2164