Provider Demographics
NPI:1225057326
Name:LONGINOTTI, JOHN ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:LONGINOTTI
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 1:804 BONNIE BRAE CT
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1128
Mailing Address - Country:US
Mailing Address - Phone:630-739-5492
Mailing Address - Fax:
Practice Address - Street 1:1144 LAKE ST
Practice Address - Street 2:SUITE 207
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-6705
Practice Address - Country:US
Practice Address - Phone:708-386-7570
Practice Address - Fax:708-386-7595
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038005479111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL749740Medicare ID - Type Unspecified