MEDICARE: ANCIENT HEALING ORIENTAL MEDICINE CLINIC S.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	261Q00000X	Clinic/Center	198000814	IL
2	111N00000X	Chiropractor	03801172	IL
3	261Q00000X	Clinic/Center	198.000814	IL

General Provider Information

NPI Number	:	1306073747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANCIENT HEALING ORIENTAL MEDICINE CLINIC S.C.

Provider Business Mailing Address
First Line	:	987 OAK KNOLL DR
Second Line	:
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-2635
Country	:	US
Telephone Number	:	847-735-9609
Fax Number	:	847-235-2439

Provider Business Practice Location Address
First Line	:	987 OAK KNOLL DR.
Second Line	:
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-2635
Country	:	US
Telephone Number	:	847-735-9609
Fax Number	:	847-235-2439

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. WIOLETTA BORECKA-KOLCAN
Credential	:	MD, OMD, L.AC.
Telephone Number	:	773-562-0734

Provider Enumeration Date	:	06/11/2009
Last Update Date	:	01/25/2011

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