MEDICARE: STRETCHCLUB NAPERVILLE 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

General Provider Information

NPI Number	:	1801516737
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STRETCHCLUB NAPERVILLE S.C.

Provider Business Mailing Address
First Line	:	47 E CHICAGO AVE STE 332B
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60540-5360
Country	:	US
Telephone Number	:	630-777-5721
Fax Number	:	630-566-5965

Provider Business Practice Location Address
First Line	:	47 E CHICAGO AVE STE 332B
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60540-5360
Country	:	US
Telephone Number	:	312-763-6542
Fax Number	:	630-566-5965

Authorized Official
Title or Position	:	OWNER
Name	:	MARK D GLYNN
Credential	:	DC
Telephone Number	:	630-777-5721

Provider Enumeration Date	:	08/31/2022
Last Update Date	:	10/21/2022

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