Provider Demographics
NPI:1003825522
Name:OAK PARK SPORT & SPINE SC
Entity Type:Organization
Organization Name:OAK PARK SPORT & SPINE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:DUDLICEK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-445-7331
Mailing Address - Street 1:127 N MARION ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1092
Mailing Address - Country:US
Mailing Address - Phone:708-445-7331
Mailing Address - Fax:708-445-7339
Practice Address - Street 1:127 N MARION ST
Practice Address - Street 2:SUITE 6
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1092
Practice Address - Country:US
Practice Address - Phone:708-445-7331
Practice Address - Fax:708-445-7339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL42618875111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty