Healthcare Provider Details

I. General information

NPI: 1982952552
Provider Name (Legal Business Name): SPORT & SPINE REHAB INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E ROOSEVELT RD JANSE HALL
LOMBARD IL
60148-4539
US

IV. Provider business mailing address

PO BOX 4588
NAPERVILLE IL
60567-4588
US

V. Phone/Fax

Practice location:
  • Phone: 262-818-3795
  • Fax: 630-277-8100
Mailing address:
  • Phone: 262-818-3795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS SOLECKI JR.
Title or Position: OWNER
Credential:
Phone: 262-818-3795