=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881096758
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY CHIROPRACTIC AND REHAB CENTER CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2014
-----------------------------------------------------
Last Update Date | 09/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4616 N WESTERN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60625-2023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-271-5070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4616 N WESTERN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60625-2023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-271-5070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AGENT
-----------------------------------------------------
Name | DR. PATRICK D BRENNAN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 330-883-1843
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038012570
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038012460
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------