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General NPI Number Information
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NPI Number | 1932654084
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Entity Type | Organization
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Legal Business Name | AXIAL SPINE & WELLNESS, LLC
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Dates
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Enumeration Date | 08/18/2016
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Last Update Date | 09/28/2020
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Provider Practice Location Address
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Address Line | 954 W WASHINGTON BLVD SUITE 110
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City | CHICAGO
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State | IL
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Zip | 60607-2224
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Country | US
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Telephone | 308-227-9071
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Fax |
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Provider Business Mailing Address
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Address Line | 954 W WASHINGTON BLVD STE 610
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City | CHICAGO
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State | IL
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Zip | 60607-2293
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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 | OWNER
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Name | TODD PETERSON
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Credential | D.C.
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Telephone | 312-523-4392
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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 | 038012711
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License Number State | IL
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