Provider Demographics
NPI: | 1366681025 |
---|---|
Name: | MARQUE MEDICOS ARCHER, LLC |
Entity Type: | Organization |
Organization Name: | MARQUE MEDICOS ARCHER, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MANAGER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | DERRICK |
Authorized Official - Middle Name: | D |
Authorized Official - Last Name: | WALLERY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DC |
Authorized Official - Phone: | 773-283-3131 |
Mailing Address - Street 1: | 4176 W MONTROSE AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | CHICAGO |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60641-2161 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 773-283-3131 |
Mailing Address - Fax: | 773-283-3610 |
Practice Address - Street 1: | 4195 S ARCHER AVE |
Practice Address - Street 2: | |
Practice Address - City: | CHICAGO |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60632-1849 |
Practice Address - Country: | US |
Practice Address - Phone: | 773-283-3131 |
Practice Address - Fax: | 773-283-3610 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-02-19 |
Last Update Date: | 2009-02-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 038008088 | 111N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 111N00000X | Chiropractic Providers | Chiropractor | Group - Multi-Specialty |