=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720152168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CECIL CHIROPRACTIC CLINIC, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2006
-----------------------------------------------------
Last Update Date | 11/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 917C W 55TH ST
-----------------------------------------------------
City | COUNTRYSIDE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60525-6613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-352-9393
-----------------------------------------------------
Fax | 708-352-5077
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4601 WOODWARD AVE
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60515-2632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-964-5117
-----------------------------------------------------
Fax | 708-352-5077
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BRIAN ALLAN CECIL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-352-9393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------