Provider Demographics
NPI:1780853119
Name:MARIO FUCINARI DC LLC
Entity Type:Organization
Organization Name:MARIO FUCINARI DC LLC
Other - Org Name:DECATUR BACK AND NECK CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:FUCINARI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:2178-772-4074
Mailing Address - Street 1:3350 N WATER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-2353
Mailing Address - Country:US
Mailing Address - Phone:217-877-2404
Mailing Address - Fax:217-877-2522
Practice Address - Street 1:3350 N WATER ST
Practice Address - Street 2:SUITE A
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-2353
Practice Address - Country:US
Practice Address - Phone:217-877-2404
Practice Address - Fax:217-877-2522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-005800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38718Medicare UPIN