Provider Demographics
NPI:1467526822
Name:BASRA, JAY (DC)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:BASRA
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 1:444 E DUNDEE RD
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60074
Mailing Address - Country:US
Mailing Address - Phone:847-879-1034
Mailing Address - Fax:847-879-1035
Practice Address - Street 1:444 E DUNDEE RD
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60074
Practice Address - Country:US
Practice Address - Phone:847-879-1034
Practice Address - Fax:847-879-1035
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38010016111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK05651Medicare UPIN