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General NPI Number Information
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NPI Number | 1881938074
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Entity Type | Organization
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Legal Business Name | BODY AND SPINE CLINIC LLC
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Dates
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Enumeration Date | 11/12/2012
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Last Update Date | 02/26/2020
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Provider Practice Location Address
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Address Line | 3037 THEODORE ST
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City | JOLIET
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State | IL
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Zip | 60435-5191
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Country | US
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Telephone | 815-582-0006
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Fax |
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Provider Business Mailing Address
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Address Line | 3037 THEODORE ST
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City | JOLIET
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State | IL
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Zip | 60435-5191
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Country | US
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Telephone | 815-582-0006
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTIC PHYSICIAN/OWNER
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Name | DR. CARISSA M BARANOSKI
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Credential | D.C.
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Telephone | 815-582-0006
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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 | 038011832
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License Number State | IL
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