Healthcare Provider Details

I. General information

NPI: 1538257118
Provider Name (Legal Business Name): DES MEDICAL CORP, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 01/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W CENTRAL RD STE 101
MT PROSPECT IL
60056-2347
US

IV. Provider business mailing address

500 W CENTRAL RD STE 101
MT PROSPECT IL
60056-2347
US

V. Phone/Fax

Practice location:
  • Phone: 847-259-6605
  • Fax: 847-259-8071
Mailing address:
  • Phone: 847-259-6605
  • Fax: 847-259-8071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038-008169
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number070-009859
License Number StateIL

VIII. Authorized Official

Name: DR. MELISSA ANN LONGO
Title or Position: OWNER
Credential: D.C.
Phone: 847-259-6605