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General NPI Number Information
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NPI Number | 1417387960
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Entity Type | Organization
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Legal Business Name | MICHIGAN AVE CHIROPRACTIC AND WELLNESS
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Dates
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Enumeration Date | 11/20/2013
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Last Update Date | 11/20/2013
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Provider Practice Location Address
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Address Line | 875 N MICHIGAN AVE STE 2519
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City | CHICAGO
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State | IL
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Zip | 60611-1803
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Country | US
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Telephone | 312-274-0711
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Fax |
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Provider Business Mailing Address
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Address Line | 875 N MICHIGAN AVE STE 2519
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City | CHICAGO
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State | IL
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Zip | 60611-1803
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. THOMAS BLAKE KIVISTO
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Credential | DC
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Telephone | 312-274-0711
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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 | 038012401
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License Number State | IL
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