Provider Demographics
NPI:1164436911
Name:BUMBALES, NICHOLAS (DC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:BUMBALES
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 1:860 SUMMIT ST
Mailing Address - Street 2:SUITE 133
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-5145
Mailing Address - Country:US
Mailing Address - Phone:847-931-4010
Mailing Address - Fax:847-931-4063
Practice Address - Street 1:860 SUMMIT ST
Practice Address - Street 2:SUITE 133
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-5145
Practice Address - Country:US
Practice Address - Phone:847-931-4010
Practice Address - Fax:847-931-4063
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T87153Medicare UPIN
IL910190Medicare ID - Type Unspecified