MEDICARE: AVALON CHIROPRACTIC P.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	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)	038009186	IL

General Provider Information

NPI Number	:	1396966933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVALON CHIROPRACTIC P.C.

Provider Business Mailing Address
First Line	:	1480 W CATALPA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1212
Country	:	US
Telephone Number	:	773-275-7977
Fax Number	:	773-275-7978

Provider Business Practice Location Address
First Line	:	1480 W CATALPA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1212
Country	:	US
Telephone Number	:	773-275-7977
Fax Number	:	773-275-7978

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STEVEN A HETTINGER
Credential	:	D.C.
Telephone Number	:	773-275-7977

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	10/25/2013

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