MEDICARE: CHIRO ONE WELLNESS CENTER METRO OF OLD TOWN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1063435402
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIRO ONE WELLNESS CENTER METRO OF OLD TOWN LLC

Provider Business Mailing Address
First Line	:	2625 BUTTERFIELD RD
Second Line	:	STE 301N
City	:	OAK BROOK
State	:	IL
Zip	:	60523-1234
Country	:	US
Telephone Number	:	630-468-1824
Fax Number	:	630-320-6489

Provider Business Practice Location Address
First Line	:	1522 N HALSTED ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-2528
Country	:	US
Telephone Number	:	312-379-5000
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	SAM WANG
Credential	:
Telephone Number	:	630-468-1824

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	10/24/2017

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