MEDICARE: BUCKTOWN CHIROPRACTIC HEALTH CENTER 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	111N00000X	Chiropractor		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	21622748	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1538287651
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUCKTOWN CHIROPRACTIC HEALTH CENTER S C

Provider Business Mailing Address
First Line	:	1952 W ARMITAGE AVE
Second Line	:	STORE FRONT
City	:	CHICAGO
State	:	IL
Zip	:	60622-1024
Country	:	US
Telephone Number	:	773-772-1010
Fax Number	:	773-772-3252

Provider Business Practice Location Address
First Line	:	1952 W ARMITAGE AVE
Second Line	:	STORE FRONT
City	:	CHICAGO
State	:	IL
Zip	:	60622-1024
Country	:	US
Telephone Number	:	773-772-1010
Fax Number	:	773-772-3252

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ESTELLE CATHERINE NELLA
Credential	:	DC
Telephone Number	:	773-772-1010

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	04/06/2011

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