Healthcare Provider Details

I. General information

NPI: 1932528940
Provider Name (Legal Business Name): OAK PARK SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 04/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1144 LAKE ST 203
OAK PARK IL
60301-6705
US

IV. Provider business mailing address

1144 LAKE ST 203
OAK PARK IL
60301-6705
US

V. Phone/Fax

Practice location:
  • Phone: 708-406-9459
  • Fax:
Mailing address:
  • Phone: 708-406-9459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number038.012565
License Number StateIL

VIII. Authorized Official

Name: DR. ARIAN A LECUONA
Title or Position: HEAD PHYSICIAN/OWNER
Credential: D.C.
Phone: 708-406-9459