Provider Demographics
NPI:1265508469
Name:MEDINAH SPINE & REHABILITATION LTD
Entity Type:Organization
Organization Name:MEDINAH SPINE & REHABILITATION LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-307-7463
Mailing Address - Street 1:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:MEDINAH
Mailing Address - State:IL
Mailing Address - Zip Code:60157
Mailing Address - Country:US
Mailing Address - Phone:630-529-0077
Mailing Address - Fax:630-529-0087
Practice Address - Street 1:7N315 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:MEDINAH
Practice Address - State:IL
Practice Address - Zip Code:60157-9799
Practice Address - Country:US
Practice Address - Phone:630-529-0077
Practice Address - Fax:630-529-0087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL138006728111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038006728Medicaid
IL208982OtherMEDICARE GRP #
IL038006728Medicaid
IL5488530001Medicare NSC
ILDC5743Medicare UPIN