=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629297486
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHISLOF CHIROPRACTIC CENTER, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2007
-----------------------------------------------------
Last Update Date | 06/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7329 N HARLEM AVE
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60714-4252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-588-0800
-----------------------------------------------------
Fax | 847-588-0811
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7329 N HARLEM AVE
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60714-4252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-588-0800
-----------------------------------------------------
Fax | 847-588-0811
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. IRA SCOTT CHISLOF
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 847-588-0800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 038004506
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------