MEDICARE: PAMELA L TICKEL DC INC.

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
2	261Q00000X	Clinic/Center	038.003947	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1902903255	OTHER	IL	NPI

General Provider Information

NPI Number	:	1164939369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAMELA L TICKEL DC INC.

Provider Business Mailing Address
First Line	:	400 N WELLS ST STE 340
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60654-2761
Country	:	US
Telephone Number	:	513-965-1851
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 N WELLS ST STE 340
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60654-2761
Country	:	US
Telephone Number	:	513-965-1851
Fax Number	:

Authorized Official
Title or Position	:	OWNER / PROVIDER
Name	:	DR. PAMELA LOUISE TICKEL
Credential	:	DC
Telephone Number	:	513-965-1851

Provider Enumeration Date	:	01/09/2018
Last Update Date	:	06/16/2018

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