=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942682968
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DUPAGE SPINE ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2015
-----------------------------------------------------
Last Update Date | 06/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 N FRANKLIN ST SUITE 407
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-8100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-426-5742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 N FRANKLIN ST SUITE 407
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-8100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-426-5742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | MR. JUSTIN FAUTSCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-795-4690
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------