Provider Demographics
NPI:1437354701
Name:PICCOLO CHIROPRACTIC CLINIC SC
Entity Type:Organization
Organization Name:PICCOLO CHIROPRACTIC CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:D
Authorized Official - Last Name:PICCOLO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-820-0000
Mailing Address - Street 1:356 N LAKE ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-4186
Mailing Address - Country:US
Mailing Address - Phone:630-820-0000
Mailing Address - Fax:630-906-1798
Practice Address - Street 1:356 N LAKE ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-4186
Practice Address - Country:US
Practice Address - Phone:630-820-0000
Practice Address - Fax:630-906-1798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38003855111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210654OtherMEDICARE PTAN