Provider Demographics
NPI:1174655450
Name:SCHULTZ, BYRON DERRIK (BS, BS, DC)
Entity Type:Individual
Prefix:DR
First Name:BYRON
Middle Name:DERRIK
Last Name:SCHULTZ
Suffix:
Gender:M
Credentials:BS, BS, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W MAPLE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-2908
Mailing Address - Country:US
Mailing Address - Phone:815-463-1130
Mailing Address - Fax:815-463-1150
Practice Address - Street 1:500 W MAPLE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2908
Practice Address - Country:US
Practice Address - Phone:815-463-1130
Practice Address - Fax:815-463-1150
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-005723111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL566370Medicare PIN
ILK47627Medicare PIN
IL481969789Medicare ID - Type Unspecified