Provider Demographics
NPI:1689684979
Name:NISIVOCCIA, GLEN JOHN (D C)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:JOHN
Last Name:NISIVOCCIA
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13129 HIDDEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-8486
Mailing Address - Country:US
Mailing Address - Phone:708-301-8723
Mailing Address - Fax:
Practice Address - Street 1:19600 LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-9321
Practice Address - Country:US
Practice Address - Phone:708-478-3000
Practice Address - Fax:708-478-3007
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038004843111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38090Medicare UPIN
IL209486Medicare PIN