Provider Demographics
NPI:1134840135
Name:KINSELLA, PETER CHARLES (DC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:CHARLES
Last Name:KINSELLA
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 1:420 LAKE ST APT K3
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2664
Mailing Address - Country:US
Mailing Address - Phone:847-650-2507
Mailing Address - Fax:
Practice Address - Street 1:1654 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2255
Practice Address - Country:US
Practice Address - Phone:872-267-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013908111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor