MEDICARE: DR. CALLISTA C FUNK DC

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	038012202	IL

General Provider Information

NPI Number	:	1295080463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CALLISTA C FUNK DC

Provider Business Mailing Address
First Line	:	917 W. WASHINGTON BLVD BOX 254
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607
Country	:	US
Telephone Number	:	312-491-8100
Fax Number	:	312-491-8501

Provider Business Practice Location Address
First Line	:	REVIVE CHIROPRACTIC HEALING CENTER
Second Line	:	1169 W MADISON ST
City	:	CHICAGO
State	:	IL
Zip	:	60607
Country	:	US
Telephone Number	:	312-491-8100
Fax Number	:	312-491-8501

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

Provider Enumeration Date	:	07/13/2012
Last Update Date	:	01/14/2025

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