Healthcare Provider Details

I. General information

NPI: 1295279719
Provider Name (Legal Business Name): REPAIR ROOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2016
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8150 MCCORMICK BLVD CONTINUUM GYM
SKOKIE IL
60076-2920
US

IV. Provider business mailing address

500 DAVIS ST SUITE 109
EVANSTON IL
60201-4668
US

V. Phone/Fax

Practice location:
  • Phone: 847-868-9609
  • Fax:
Mailing address:
  • Phone: 847-868-9609
  • Fax: 847-990-7944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.012514
License Number StateIL

VIII. Authorized Official

Name: BENJAMIN FERGUS
Title or Position: OWNER
Credential:
Phone: 847-868-9609