Healthcare Provider Details

I. General information

NPI: 1316997554
Provider Name (Legal Business Name): THEODOROS MIKROULIS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 HARLEM AVE
LYONS IL
60534-1289
US

IV. Provider business mailing address

3840 HARLEM AVE
LYONS IL
60534-1289
US

V. Phone/Fax

Practice location:
  • Phone: 708-442-3050
  • Fax: 708-442-3058
Mailing address:
  • Phone: 708-442-3050
  • Fax: 708-442-3058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: