Provider Demographics
NPI:1689712804
Name:OLD TOWN CHIROPRACTIC CENTER PC
Entity Type:Organization
Organization Name:OLD TOWN CHIROPRACTIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-893-7313
Mailing Address - Street 1:160 S. BLOOMINGDALE RD.
Mailing Address - Street 2:SUITE D
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1455
Mailing Address - Country:US
Mailing Address - Phone:630-893-7313
Mailing Address - Fax:630-893-7453
Practice Address - Street 1:160 S BLOOMINGDALE RD
Practice Address - Street 2:SUITE D
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1479
Practice Address - Country:US
Practice Address - Phone:630-893-7313
Practice Address - Fax:630-893-7453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006619111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL955440Medicare ID - Type Unspecified