=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073929204
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELTA CHIROPRACTIC AND DECOMPRESSION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2014
-----------------------------------------------------
Last Update Date | 02/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 43 W ACORN LN
-----------------------------------------------------
City | LAKE IN THE HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60156-4804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-854-5356
-----------------------------------------------------
Fax | 847-854-5436
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43 W ACORN LN
-----------------------------------------------------
City | LAKE IN THE HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60156-4804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-854-5356
-----------------------------------------------------
Fax | 847-854-5436
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCTOR
-----------------------------------------------------
Name | NATHAN A STEWART
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 815-909-8494
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0380011807
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------