Provider Demographics
NPI:1184038366
Name:CHICAGO SPORT AND WELLNESS
Entity Type:Organization
Organization Name:CHICAGO SPORT AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/ CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNIL
Authorized Official - Middle Name:SIMON
Authorized Official - Last Name:PULLUKAT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-852-8423
Mailing Address - Street 1:5306 N RUTHERFORD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-2131
Mailing Address - Country:US
Mailing Address - Phone:773-852-8423
Mailing Address - Fax:
Practice Address - Street 1:1200 OLD SKOKIE VALLEY RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-3036
Practice Address - Country:US
Practice Address - Phone:773-852-8423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012256111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty