Provider Demographics
NPI:1174668438
Name:KOWASZ-MCKIM, MELISSA REA (DC)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:REA
Last Name:KOWASZ-MCKIM
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 1:820 E TERRA COTTA AVE
Mailing Address - Street 2:STE 141
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-3649
Mailing Address - Country:US
Mailing Address - Phone:815-477-7718
Mailing Address - Fax:815-477-7121
Practice Address - Street 1:820 E TERRA COTTA AVE
Practice Address - Street 2:STE 141
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3649
Practice Address - Country:US
Practice Address - Phone:815-477-7718
Practice Address - Fax:815-477-7121
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
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
ILV00425Medicare UPIN
ILK18963Medicare ID - Type UnspecifiedGROUP ID IS 211959