MEDICARE: VILLA PARK CHIROPRACTIC CENTER, LTD.

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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	02232410	OTHER	IL	BCBSIL

General Provider Information

NPI Number	:	1487623302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLA PARK CHIROPRACTIC CENTER, LTD.

Provider Business Mailing Address
First Line	:	411 W SAINT CHARLES RD
Second Line	:
City	:	VILLA PARK
State	:	IL
Zip	:	60181-2432
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	411 W SAINT CHARLES RD
Second Line	:
City	:	VILLA PARK
State	:	IL
Zip	:	60181-2432
Country	:	US
Telephone Number	:	630-691-1234
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARY LUTHER
Credential	:	DC
Telephone Number	:	630-691-1234

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	03/28/2008

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