Provider Demographics
NPI:1629222054
Name:DECUBELLIS, MICHAEL EDWARD (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:DECUBELLIS
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 1:5157 MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-4616
Mailing Address - Country:US
Mailing Address - Phone:630-435-6461
Mailing Address - Fax:630-960-9924
Practice Address - Street 1:5157 MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-4616
Practice Address - Country:US
Practice Address - Phone:630-435-6461
Practice Address - Fax:630-960-9924
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-12
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-011235111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2004001OtherMEDICARE PTAN