Provider Demographics
NPI:1487201109
Name:MEDINA TREVINO, ANTONIO MANUEL (DC)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:MANUEL
Last Name:MEDINA TREVINO
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 1:225 W HUBBARD ST STE 302
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-4916
Mailing Address - Country:US
Mailing Address - Phone:312-216-2447
Mailing Address - Fax:
Practice Address - Street 1:225 W HUBBARD ST STE 302
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-4916
Practice Address - Country:US
Practice Address - Phone:312-216-2447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38.013414111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist