Provider Demographics
NPI:1275955619
Name:POLICASTRO, PAM (L AC)
Entity Type:Individual
Prefix:MRS
First Name:PAM
Middle Name:
Last Name:POLICASTRO
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4753 N BROADWAY ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-4998
Mailing Address - Country:US
Mailing Address - Phone:773-271-8284
Mailing Address - Fax:773-271-9139
Practice Address - Street 1:4753 N BROADWAY ST STE 101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4998
Practice Address - Country:US
Practice Address - Phone:773-271-8284
Practice Address - Fax:773-271-9139
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-18
Last Update Date:2014-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL364427599111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN364427599Medicaid