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General NPI Number Information
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NPI Number | 1689712804
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Entity Type | Organization
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Legal Business Name | OLD TOWN CHIROPRACTIC CENTER PC
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Dates
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Enumeration Date | 02/01/2007
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Last Update Date | 05/23/2012
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Provider Practice Location Address
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Address Line | 160 S BLOOMINGDALE RD SUITE D
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-1479
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Country | US
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Telephone | 630-893-7313
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Fax | 630-893-7453
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Provider Business Mailing Address
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Address Line | 160 S. BLOOMINGDALE RD. SUITE D
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-1455
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Country | US
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Telephone | 630-893-7313
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Fax | 630-893-7453
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Authorized Official
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Title or Position | CHIROPRACTIC OWNER
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Name | DR. MICHAEL DAVID KELLY
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Credential | D.C.
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Telephone | 630-893-7313
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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 | 038006619
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License Number State | IL
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