Healthcare Provider Details

I. General information

NPI: 1275772154
Provider Name (Legal Business Name): CHRISTOPHER CHALK, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2009
Last Update Date: 10/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 WINDSOR RD STE.A
LOVES PARK IL
61111-4271
US

IV. Provider business mailing address

1820 WINDSOR RD STE.A
LOVES PARK IL
61111-4271
US

V. Phone/Fax

Practice location:
  • Phone: 815-986-4411
  • Fax:
Mailing address:
  • Phone: 815-986-4411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number038006422
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036097622
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number038006422
License Number StateIL

VIII. Authorized Official

Name: DR. CHRISTOPHER SCOTT CHALK
Title or Position: PRESIDENT
Credential: DC
Phone: 815-986-4411