Provider Demographics
NPI:1235495623
Name:MEDLOCK, MICHAEL BRODIE (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRODIE
Last Name:MEDLOCK
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 1:1300 IROQUOIS AVE
Mailing Address - Street 2:SUITE 270
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563
Mailing Address - Country:US
Mailing Address - Phone:630-428-0201
Mailing Address - Fax:
Practice Address - Street 1:1300 IROQUOIS AVE
Practice Address - Street 2:SUITE 270
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8553
Practice Address - Country:US
Practice Address - Phone:630-428-0201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.012161111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor