Provider Demographics
NPI:1558464131
Name:PICCOLO, GEORGE DOMINICK (DC)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:DOMINICK
Last Name:PICCOLO
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 1:356 N LAKE ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506
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
Practice Address - Country:US
Practice Address - Phone:630-820-0000
Practice Address - Fax:630-906-1798
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4582035OtherBLUE CROSS
Y24373Medicare UPIN
210654Medicare ID - Type Unspecified