MEDICARE: DR. MARK JOSEPH MCKIM D.C.

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		IL

General Provider Information

NPI Number	:	1134264484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK JOSEPH MCKIM D.C.

Provider Business Mailing Address
First Line	:	820 E TERRA COTTA AVE
Second Line	:	STE 141
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-3649
Country	:	US
Telephone Number	:	815-477-7718
Fax Number	:	815-477-7121

Provider Business Practice Location Address
First Line	:	820 E TERRA COTTA AVE
Second Line	:	STE 141
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-3649
Country	:	US
Telephone Number	:	815-477-7718
Fax Number	:	815-477-7121

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/08/2007

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