Provider Demographics
NPI:1720318934
Name:ILLINOIS CENTER FOR PROGRESSIVE HEALTH, SC
Entity Type:Organization
Organization Name:ILLINOIS CENTER FOR PROGRESSIVE HEALTH, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LEROY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:312-243-3338
Mailing Address - Street 1:1002 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1715
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1002 W LAKE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-1715
Practice Address - Country:US
Practice Address - Phone:312-243-3338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007739111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL001607135OtherBCBS
IL001607135OtherBCBS
IL372681Medicare PIN