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General NPI Number Information
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NPI Number | 1710145933
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Entity Type | Organization
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Legal Business Name | BIOTIDAL TECHNOLOGY, INC
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Dates
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Enumeration Date | 05/23/2008
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Last Update Date | 05/23/2008
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Provider Practice Location Address
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Address Line | 3354 N PAULINA ST SUITE 206C
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City | CHICAGO
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State | IL
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Zip | 60657-1068
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Country | US
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Telephone | 773-991-5131
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Fax |
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Provider Business Mailing Address
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Address Line | 4103 W POTOMAC AVE
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City | CHICAGO
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State | IL
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Zip | 60651-1853
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Country | US
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Telephone | 773-486-9546
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. GREGG S HORIGAN
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Credential | D.C.
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Telephone | 773-991-5131
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 038-006984
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License Number State | IL
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