Provider Demographics
NPI:1972591840
Name:IAVARONE, GREGORY SPEEDY (DC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:SPEEDY
Last Name:IAVARONE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 W LAKE ST
Mailing Address - Street 2:17
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-5744
Mailing Address - Country:US
Mailing Address - Phone:630-628-7881
Mailing Address - Fax:630-628-7393
Practice Address - Street 1:1250 W LAKE ST
Practice Address - Street 2:17
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-5744
Practice Address - Country:US
Practice Address - Phone:630-543-7246
Practice Address - Fax:630-907-9015
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008341111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL532770Medicare ID - Type Unspecified
ILU73803Medicare UPIN