MEDICARE: WONDER LAKE CHIROPRACTIC, 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	261Q00000X	Clinic/Center	038006125	IL

General Provider Information

NPI Number	:	1134541428
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WONDER LAKE CHIROPRACTIC, LLC

Provider Business Mailing Address
First Line	:	5323 E WONDER LAKE RD
Second Line	:
City	:	WONDER LAKE
State	:	IL
Zip	:	60097-9051
Country	:	US
Telephone Number	:	815-728-0300
Fax Number	:	815-728-1515

Provider Business Practice Location Address
First Line	:	5323 E WONDER LAKE RD
Second Line	:
City	:	WONDER LAKE
State	:	IL
Zip	:	60097-9051
Country	:	US
Telephone Number	:	815-728-0300
Fax Number	:	815-728-1515

Authorized Official
Title or Position	:	CHIROPRACTIC PHYSICIAN/OWNER
Name	:	DR. METE A. DURUM
Credential	:	D.C., D.A.B.C.I.
Telephone Number	:	815-728-0300

Provider Enumeration Date	:	01/06/2014
Last Update Date	:	01/06/2014

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