Provider Demographics
NPI:1457496028
Name:ECONOMOU, THEODORE XENOPHON (DR OF CHIROPRACTIC)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:XENOPHON
Last Name:ECONOMOU
Suffix:
Gender:M
Credentials:DR OF CHIROPRACTIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1644 45TH STREET
Mailing Address - Street 2:SUITE F 45TH AVE PROFESSIONAL CENTER
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3971
Mailing Address - Country:US
Mailing Address - Phone:219-924-5735
Mailing Address - Fax:
Practice Address - Street 1:1644 45TH STREET
Practice Address - Street 2:SUITE F
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3971
Practice Address - Country:US
Practice Address - Phone:219-924-5735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000291A111N00000X
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T36446Medicare UPIN