Healthcare Provider Details

I. General information

NPI: 1093070567
Provider Name (Legal Business Name): ST. CHARLES SERVICE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 W. MAIN STREET
ST. CHARLES IL
60174
US

IV. Provider business mailing address

260 E. ARMY TRAIL RD, SUITE D
BARTLETT IL
60103-3005
US

V. Phone/Fax

Practice location:
  • Phone: 630-830-8600
  • Fax: 630-830-2273
Mailing address:
  • Phone: 630-830-8600
  • Fax: 630-830-2273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038007980
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name: PASQUALE G. CALCAGNO
Title or Position: DOCTOR OF CHIROPRACTIC
Credential: DC
Phone: 630-830-8600