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General NPI Number Information
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NPI Number | 1629539291
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Entity Type | Organization
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Legal Business Name | SOUTHPORT GRACE CHIROPRACTIC AND WELLNESS LLC
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Dates
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Enumeration Date | 03/27/2019
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Last Update Date | 05/08/2019
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Provider Practice Location Address
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Address Line | 1209 W GRACE ST
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City | CHICAGO
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State | IL
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Zip | 60613-2805
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Country | US
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Telephone | 772-525-2225
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Fax |
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Provider Business Mailing Address
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Address Line | 1209 W GRACE ST STE 1
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City | CHICAGO
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State | IL
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Zip | 60613-2805
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Country | US
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Telephone | 772-525-2225
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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. KEITH OLDING
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Credential | DC
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Telephone | 419-628-4003
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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 |
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License Number State |
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