Provider Demographics
NPI:1326091372
Name:CISSELL, DARREN (DC)
Entity Type:Individual
Prefix:DR
First Name:DARREN
Middle Name:
Last Name:CISSELL
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 1:104 N. RIDGE RD.
Mailing Address - Street 2:SUITE 144
Mailing Address - City:MINOOKA
Mailing Address - State:IL
Mailing Address - Zip Code:60447-9875
Mailing Address - Country:US
Mailing Address - Phone:815-467-1464
Mailing Address - Fax:815-521-0492
Practice Address - Street 1:104 N. RIDGE RD.
Practice Address - Street 2:SUITE 144
Practice Address - City:MINOOKA
Practice Address - State:IL
Practice Address - Zip Code:60447-9875
Practice Address - Country:US
Practice Address - Phone:815-467-1464
Practice Address - Fax:815-521-0492
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009977111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK14500Medicare UPIN