MEDICARE: DR. JAMIE LEE VANDENELZEN D.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	038011879	IL

General Provider Information

NPI Number	:	1700182243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMIE LEE VANDENELZEN D.C.

Provider Business Mailing Address
First Line	:	2414 W THOMAS ST # 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-3531
Country	:	US
Telephone Number	:	920-217-6052
Fax Number	:	708-377-5704

Provider Business Practice Location Address
First Line	:	2414 W THOMAS ST # 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-3531
Country	:	US
Telephone Number	:	920-217-6052
Fax Number	:	708-377-5704

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2011
Last Update Date	:	03/31/2014

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