Provider Demographics
NPI:1619649001
Name:ILLINOIS SPINE AND SPORT LLC
Entity Type:Organization
Organization Name:ILLINOIS SPINE AND SPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:SEBBY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-228-0992
Mailing Address - Street 1:2 NORTHFIELD PLZ STE 100
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-1217
Mailing Address - Country:US
Mailing Address - Phone:847-957-8660
Mailing Address - Fax:
Practice Address - Street 1:2 NORTHFIELD PLZ STE 100
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-1217
Practice Address - Country:US
Practice Address - Phone:815-228-0992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-04
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038011836OtherCHIROPRACTIC LICENSE