=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134512668
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHBROOK CHIROPRACTIC AND NATURAL CARE CENTER SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2015
-----------------------------------------------------
Last Update Date | 06/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 SHERMER RD STE 1SE
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-5343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-817-2273
-----------------------------------------------------
Fax | 224-415-3706
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 SHERMER RD STE 1SE
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-5343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-817-2273
-----------------------------------------------------
Fax | 224-415-3706
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BORIS VELLER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 224-817-2273
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 038010408
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------