Provider Demographics
NPI:1710145933
Name:BIOTIDAL TECHNOLOGY, INC
Entity Type:Organization
Organization Name:BIOTIDAL TECHNOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:S
Authorized Official - Last Name:HORIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-991-5131
Mailing Address - Street 1:4103 W POTOMAC AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-1853
Mailing Address - Country:US
Mailing Address - Phone:773-486-9546
Mailing Address - Fax:
Practice Address - Street 1:3354 N PAULINA ST
Practice Address - Street 2:SUITE 206C
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-1068
Practice Address - Country:US
Practice Address - Phone:773-991-5131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-006984261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center