Provider Demographics
NPI:1831780303
Name:DR SPINE CHIROPRACTIC AND ACUPUNCTURE LLC
Entity type:Organization
Organization Name:DR SPINE CHIROPRACTIC AND ACUPUNCTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRETTI
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTALVO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:864-401-2113
Mailing Address - Street 1:3550 N LAKE SHORE DR APT 2220
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-7869
Mailing Address - Country:US
Mailing Address - Phone:864-401-2113
Mailing Address - Fax:
Practice Address - Street 1:561 W DIVERSEY PKWY STE 221
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1682
Practice Address - Country:US
Practice Address - Phone:864-401-2113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-28
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service