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General NPI Number Information
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NPI Number | 1720318934
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Entity Type | Organization
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Legal Business Name | ILLINOIS CENTER FOR PROGRESSIVE HEALTH, SC
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Dates
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Enumeration Date | 01/11/2010
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Last Update Date | 05/11/2010
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Provider Practice Location Address
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Address Line | 1002 W LAKE ST
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City | CHICAGO
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State | IL
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Zip | 60607-1715
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Country | US
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Telephone | 312-243-3338
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Fax |
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Provider Business Mailing Address
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Address Line | 1002 W LAKE ST
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City | CHICAGO
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State | IL
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Zip | 60607-1715
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | NICHOLAS LEROY
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Credential | DC
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Telephone | 312-243-3338
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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 | 038007739
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License Number State | IL
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