Provider Demographics
NPI:1205956604
Name:SPORTS AND SPINE REHAB S.C.
Entity type:Organization
Organization Name:SPORTS AND SPINE REHAB S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-464-7113
Mailing Address - Street 1:39 BANKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-3112
Mailing Address - Country:US
Mailing Address - Phone:815-464-7113
Mailing Address - Fax:815-464-7192
Practice Address - Street 1:39 W. BANKVIEW DR
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-3112
Practice Address - Country:US
Practice Address - Phone:815-464-7113
Practice Address - Fax:815-464-7192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09919991OtherBCBSIL
IL216035Medicare PIN