Provider Demographics
NPI:1295080463
Name:FUNK, CALLISTA C (DC)
Entity type:Individual
Prefix:DR
First Name:CALLISTA
Middle Name:C
Last Name:FUNK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 W. WASHINGTON BLVD BOX 254
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607
Mailing Address - Country:US
Mailing Address - Phone:312-491-8100
Mailing Address - Fax:312-491-8501
Practice Address - Street 1:REVIVE CHIROPRACTIC HEALING CENTER
Practice Address - Street 2:1169 W MADISON ST
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607
Practice Address - Country:US
Practice Address - Phone:312-491-8100
Practice Address - Fax:312-491-8501
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor