Provider Demographics
NPI:1184163628
Name:SURPRENANT CHIROPRACTIC LLC
Entity type:Organization
Organization Name:SURPRENANT CHIROPRACTIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:REGINA
Authorized Official - Last Name:SURPRENANT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-651-4921
Mailing Address - Street 1:1227 N ILLINOIS RT 83
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030
Mailing Address - Country:US
Mailing Address - Phone:847-548-4800
Mailing Address - Fax:
Practice Address - Street 1:1227 N ILLINOIS ROUTE 83
Practice Address - Street 2:SUITE A
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030
Practice Address - Country:US
Practice Address - Phone:847-548-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.012253261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center