Provider Demographics
NPI:1003376245
Name:CHICAGO ANTI AGING INSTITUTE SC
Entity Type:Organization
Organization Name:CHICAGO ANTI AGING INSTITUTE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-267-2164
Mailing Address - Street 1:16622 W 159TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-8015
Mailing Address - Country:US
Mailing Address - Phone:815-838-7746
Mailing Address - Fax:815-838-5090
Practice Address - Street 1:16622 W 159TH ST STE 500
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-8015
Practice Address - Country:US
Practice Address - Phone:815-838-7746
Practice Address - Fax:815-838-5090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty