=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568724292
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATRICK MALARTSIK DC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2012
-----------------------------------------------------
Last Update Date | 06/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 W ONTARIO ST SUITE 150
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60654-6957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-253-5926
-----------------------------------------------------
Fax | 312-943-0930
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 W ONTARIO ST SUITE 150
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60654-6957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-253-5926
-----------------------------------------------------
Fax | 312-943-0930
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING COORDINATOR
-----------------------------------------------------
Name | LYNNETTE MCROY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-767-3822
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038012023
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------