MEDICARE: CHIROPRACTIC PLUS

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	038005092	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0040143639	OTHER	IL	BCBS
2	0024940161	OTHER	IL	BCBS
3	4915298	OTHER	IL	BCBSIL

General Provider Information

NPI Number	:	1831385434
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIROPRACTIC PLUS

Provider Business Mailing Address
First Line	:	3930 WASHINGTON ST
Second Line	:	SUITE B
City	:	GURNEE
State	:	IL
Zip	:	60031-5702
Country	:	US
Telephone Number	:	847-662-1600
Fax Number	:	847-662-1612

Provider Business Practice Location Address
First Line	:	3930 WASHINGTON ST
Second Line	:	SUITE B
City	:	GURNEE
State	:	IL
Zip	:	60031-5702
Country	:	US
Telephone Number	:	847-662-1600
Fax Number	:	847-662-1612

Authorized Official
Title or Position	:	OWNER/DOCTOR
Name	:	MARK FREDRICK
Credential	:	D.C.
Telephone Number	:	847-662-1600

Provider Enumeration Date	:	09/18/2007
Last Update Date	:	10/06/2010

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Directions to “CHIROPRACTIC PLUS ” Practice Location

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