MEDICARE: MAIN STREET CHIROPRACTIC AND WELLNESS CENTER LTD

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	261QM2500X	Medical Specialty Clinic/Center	042.619502	IL

General Provider Information

NPI Number	:	1124253836
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAIN STREET CHIROPRACTIC AND WELLNESS CENTER LTD

Provider Business Mailing Address
First Line	:	6234 S MAIN ST
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60516
Country	:	US
Telephone Number	:	630-435-6461
Fax Number	:

Provider Business Practice Location Address
First Line	:	6234 S MAIN STREET
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60516
Country	:	US
Telephone Number	:	630-435-6461
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CHIROPRACTOR
Name	:	DR. MIKE DECUBELLIS
Credential	:	D.C.
Telephone Number	:	630-435-6461

Provider Enumeration Date	:	05/26/2009
Last Update Date	:	06/04/2009

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