Provider Demographics
NPI:1396575502
Name:FAGAN, CONNOR (DC)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:FAGAN
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 1:2736 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-4201
Mailing Address - Country:US
Mailing Address - Phone:630-963-0080
Mailing Address - Fax:630-963-0341
Practice Address - Street 1:2736 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-4201
Practice Address - Country:US
Practice Address - Phone:630-963-0080
Practice Address - Fax:630-963-0341
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.014167111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty