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General NPI Number Information
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NPI Number | 1316086267
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Entity Type | Organization
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Legal Business Name | SUNSPOT SPINAL & SPORTS REHABILITATION
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Dates
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Enumeration Date | 02/06/2007
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Last Update Date | 02/07/2011
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Provider Practice Location Address
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Address Line | 8224 LINDENWOOD LN
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City | WOODRIDGE
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State | IL
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Zip | 60517-4105
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Country | US
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Telephone | 630-615-0656
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2210 105 CANTERBURY LN
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City | BOLINGBROOK
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State | IL
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Zip | 60440-0138
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Country | US
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Telephone | 630-615-0656
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. CHARLES NATHAN BODEM
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Credential | D.C.
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Telephone | 630-615-0656
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 042617979
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 042617979
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License Number State | IL
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