Healthcare Provider Details

I. General information

NPI: 1881273910
Provider Name (Legal Business Name): CHIRO ONE WELLNESS CENTER OF BROAD RIPPLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5858 N COLLEGE AVE
INDIANAPOLIS IN
46220-2552
US

IV. Provider business mailing address

2625 BUTTERFIELD RD STE 301N
OAK BROOK IL
60523-1266
US

V. Phone/Fax

Practice location:
  • Phone: 317-401-8075
  • Fax:
Mailing address:
  • Phone: 630-229-4430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SAM WANG
Title or Position: COO
Credential: DC
Phone: 630-468-1824