Provider Demographics
NPI:1396841011
Name:MONCEBAIZ, RICHARD (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:MONCEBAIZ
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 1:9543 NORMANDY AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2129
Mailing Address - Country:US
Mailing Address - Phone:708-430-2138
Mailing Address - Fax:708-430-2138
Practice Address - Street 1:5623 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2220
Practice Address - Country:US
Practice Address - Phone:708-863-1001
Practice Address - Fax:708-863-2649
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-006012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0168274734OtherBCBS
ILT38866Medicare UPIN
IL773460Medicare ID - Type Unspecified