Provider Demographics
NPI:1164062626
Name:PETRARCA, ANTHONY (DC)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:PETRARCA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 N MARLEY RD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1381
Mailing Address - Country:US
Mailing Address - Phone:847-980-0667
Mailing Address - Fax:
Practice Address - Street 1:3842 HARLEM AVE # 44
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:IL
Practice Address - Zip Code:60534-1219
Practice Address - Country:US
Practice Address - Phone:708-442-3050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013496111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor