Provider Demographics
NPI:1235120825
Name:ANTIOCH FAMILY CHIROPRACTIC INC
Entity Type:Organization
Organization Name:ANTIOCH FAMILY CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-838-0688
Mailing Address - Street 1:960 VICTORIA ST
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-1519
Mailing Address - Country:US
Mailing Address - Phone:847-838-0688
Mailing Address - Fax:847-838-0690
Practice Address - Street 1:960 VICTORIA ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-1519
Practice Address - Country:US
Practice Address - Phone:847-838-0688
Practice Address - Fax:847-838-0690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL344470Medicare ID - Type Unspecified
U49436Medicare UPIN