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General NPI Number Information
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NPI Number | 1962882209
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Entity Type | Organization
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Legal Business Name | PRIMAL CHIROPRACTIC LTD.
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Dates
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Enumeration Date | 06/02/2015
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Last Update Date | 06/02/2015
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Provider Practice Location Address
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Address Line | 12211 S HARLEM AVE STE 1S
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City | PALOS HEIGHTS
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State | IL
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Zip | 60463-1471
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Country | US
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Telephone | 708-671-8082
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Fax | 708-777-4764
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Provider Business Mailing Address
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Address Line | 12211 S HARLEM AVE STE 1S
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City | PALOS HEIGHTS
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State | IL
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Zip | 60463-1471
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Country | US
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Telephone | 708-671-8082
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Fax | 708-777-4764
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RYAN JON GAWRON
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Credential | D.C.
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Telephone | 708-671-8082
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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 | 038012701
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License Number State | IL
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