Provider Demographics
NPI:1003137704
Name:CONNELLY CHIROPRACTIC
Entity Type:Organization
Organization Name:CONNELLY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:312-927-3753
Mailing Address - Street 1:777 OAKMONT LN
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5511
Mailing Address - Country:US
Mailing Address - Phone:630-323-2225
Mailing Address - Fax:630-323-5230
Practice Address - Street 1:777 OAKMONT LN
Practice Address - Street 2:SUITE 1000
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-5511
Practice Address - Country:US
Practice Address - Phone:630-323-2225
Practice Address - Fax:630-323-5230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0388008991111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty