MEDICARE: CHICAGO CHIROPRACTIC & SPORTS INJURY CENTER

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	111NS0005X	Sports Physician Chiropractor		IL

General Provider Information

NPI Number	:	1831301522
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO CHIROPRACTIC & SPORTS INJURY CENTER

Provider Business Mailing Address
First Line	:	2654 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1307
Country	:	US
Telephone Number	:	773-529-5670
Fax Number	:	773-529-5672

Provider Business Practice Location Address
First Line	:	2654 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1307
Country	:	US
Telephone Number	:	773-529-5670
Fax Number	:	773-529-5672

Authorized Official
Title or Position	:	OWNER AND CHIROPRACTOR
Name	:	DR. ALDEN C. CLENDENIN
Credential	:	D.C.
Telephone Number	:	773-529-5670

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	08/22/2020

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