=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174646483
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LARDI CHIROPRACTIC LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2007
-----------------------------------------------------
Last Update Date | 01/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 495 E 1ST ST
-----------------------------------------------------
City | COAL CITY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60416-1633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-634-3750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 495 E 1ST ST
-----------------------------------------------------
City | COAL CITY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60416-1633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KELLY LARDI
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 815-634-3750
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038-007152
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------