Provider Demographics
NPI:1508071135
Name:CHIROPRACTIC MEDICINE & ASSOCIATES OF DUPAGE
Entity Type:Organization
Organization Name:CHIROPRACTIC MEDICINE & ASSOCIATES OF DUPAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANKLIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-510-7774
Mailing Address - Street 1:1984 SPRING GREEN DR
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-7254
Mailing Address - Country:US
Mailing Address - Phone:630-510-7774
Mailing Address - Fax:
Practice Address - Street 1:1600 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3145
Practice Address - Country:US
Practice Address - Phone:630-510-7774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038003478111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0100XChiropractic ProvidersChiropractorOccupational HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1548351216OtherNATIONAL PROV TYPE 1 ID
IL2290080OtherIL BCBS NUMBER
IL345860Medicare ID - Type Unspecified
1548351216OtherNATIONAL PROV TYPE 1 ID