1710079710 NPI number — CHIRO-MED SPORTS CLINIC, INC.

Table of content: MR. MICHAEL ANTHONY JORDON JR. B.S. PSYCHOLOGY, CCS (NPI 1558794636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710079710 NPI number — CHIRO-MED SPORTS CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIRO-MED SPORTS CLINIC, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BODIES IN BALANCE CHIROPRACTIC AND WELLNESS CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710079710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3100 DUNDEE RD
Provider Second Line Business Mailing Address:
SUITE 506
Provider Business Mailing Address City Name:
NORTHBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60062-2437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-562-0888
Provider Business Mailing Address Fax Number:
847-562-0842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 DUNDEE ROAD
Provider Second Line Business Practice Location Address:
SUITE 506
Provider Business Practice Location Address City Name:
NORTHBROOK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60062-2437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-562-0888
Provider Business Practice Location Address Fax Number:
847-562-0842
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STEIN
Authorized Official First Name:
HAL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-562-0888

Provider Taxonomy Codes

  • Taxonomy code: 111NI0900X , with the licence number:  038007974 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1620955 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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