=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871224642
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEARDED CHIRO INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2022
-----------------------------------------------------
Last Update Date | 06/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 442 E ROOSEVELT RD
-----------------------------------------------------
City | LOMBARD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60148-4630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-261-0001
-----------------------------------------------------
Fax | 331-200-3123
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 442 E ROOSEVELT RD
-----------------------------------------------------
City | LOMBARD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60148-4630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-261-0001
-----------------------------------------------------
Fax | 331-200-3123
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JAMES SRONKOSKI
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 630-261-0001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------