MEDICARE: LA CLINICA SC

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	042620268	IL

General Provider Information

NPI Number	:	1336504471
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA CLINICA SC

Provider Business Mailing Address
First Line	:	PO BOX 4782
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60680-4782
Country	:	US
Telephone Number	:	773-278-9525
Fax Number	:	708-337-9135

Provider Business Practice Location Address
First Line	:	4123 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-2105
Country	:	US
Telephone Number	:	773-278-9525
Fax Number	:	708-337-9135

Authorized Official
Title or Position	:	OWNER
Name	:	MR. EUGENE JAO
Credential	:	DC
Telephone Number	:	312-961-6611

Provider Enumeration Date	:	12/16/2015
Last Update Date	:	12/16/2015

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Directions to “LA CLINICA SC ” Practice Location

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