Provider Demographics
NPI:1326373028
Name:DC SPINAL WELLNESS & SPORTS REHABILITATION LTD
Entity Type:Organization
Organization Name:DC SPINAL WELLNESS & SPORTS REHABILITATION LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-916-8533
Mailing Address - Street 1:310 SOUTH MAIN STREET
Mailing Address - Street 2:310E
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4392
Mailing Address - Country:US
Mailing Address - Phone:630-916-8533
Mailing Address - Fax:630-916-8538
Practice Address - Street 1:310 S MAIN ST
Practice Address - Street 2:310E
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-2691
Practice Address - Country:US
Practice Address - Phone:630-916-8533
Practice Address - Fax:630-916-8538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-14
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008821111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U84780Medicare UPIN
IL703080Medicare PIN