Provider Demographics
NPI:1114030228
Name:ST. JOHN, TAMARA (DC)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:ST. JOHN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CARPENTERSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60110-1732
Mailing Address - Country:US
Mailing Address - Phone:630-935-2791
Mailing Address - Fax:
Practice Address - Street 1:160 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CARPENTERSVILLE
Practice Address - State:IL
Practice Address - Zip Code:60110-1732
Practice Address - Country:US
Practice Address - Phone:630-935-2791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007451111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2207639OtherBCBSI
P149948OtherRAILROAD MEDICARE
P149948OtherRAILROAD MEDICARE
570070Medicare ID - Type Unspecified