Provider Demographics
NPI:1679641930
Name:LA CLINICA, S.C.
Entity Type:Organization
Organization Name:LA CLINICA, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:MARIO
Authorized Official - Last Name:JAO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-329-0039
Mailing Address - Street 1:5832 W CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-2133
Mailing Address - Country:US
Mailing Address - Phone:708-329-0039
Mailing Address - Fax:708-329-0040
Practice Address - Street 1:5832 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2133
Practice Address - Country:US
Practice Address - Phone:708-329-0039
Practice Address - Fax:708-329-0040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILV07980Medicare UPIN
IL212833Medicare ID - Type UnspecifiedLA CLINICA, S.C.
ILV07979Medicare UPIN