MEDICARE: CHICAGO CENTER FOR PSYCHOPHYSICAL HEALING

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	171100000X	Acupuncturist	198.000412	IL
2	171100000X	Acupuncturist	198.000302	IL

General Provider Information

NPI Number	:	1417197955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO CENTER FOR PSYCHOPHYSICAL HEALING

Provider Business Mailing Address
First Line	:	1622 W DEVON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-1214
Country	:	US
Telephone Number	:	773-764-0960
Fax Number	:

Provider Business Practice Location Address
First Line	:	1622 W DEVON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-1214
Country	:	US
Telephone Number	:	773-764-0960
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. JOHN R NORTHAGE JR.
Credential	:	L.AC
Telephone Number	:	773-764-0960

Provider Enumeration Date	:	02/24/2009
Last Update Date	:	02/24/2009

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Directions to “CHICAGO CENTER FOR PSYCHOPHYSICAL HEALING ” Practice Location

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