Provider Demographics
NPI:1710079710
Name:CHIRO-MED SPORTS CLINIC, INC.
Entity Type:Organization
Organization Name:CHIRO-MED SPORTS CLINIC, INC.
Other - Org Name:BODIES IN BALANCE CHIROPRACTIC AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HAL
Authorized Official - Middle Name:
Authorized Official - Last Name:STEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-562-0888
Mailing Address - Street 1:3100 DUNDEE RD
Mailing Address - Street 2:SUITE 506
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2437
Mailing Address - Country:US
Mailing Address - Phone:847-562-0888
Mailing Address - Fax:847-562-0842
Practice Address - Street 1:3100 DUNDEE ROAD
Practice Address - Street 2:SUITE 506
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2437
Practice Address - Country:US
Practice Address - Phone:847-562-0888
Practice Address - Fax:847-562-0842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2012-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007974111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0900XChiropractic ProvidersChiropractorInternistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1620955OtherBCBS