Provider Demographics
NPI:1134420011
Name:BANNOCKBURN CHIROPRACTIC & SPORTS INJURY CENTER PC
Entity type:Organization
Organization Name:BANNOCKBURN CHIROPRACTIC & SPORTS INJURY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:EVAN
Authorized Official - Last Name:YOSS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-236-1194
Mailing Address - Street 1:2101 WAUKEGAN RD
Mailing Address - Street 2:100
Mailing Address - City:BANNOCKBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60015-1836
Mailing Address - Country:US
Mailing Address - Phone:847-236-1194
Mailing Address - Fax:847-236-1195
Practice Address - Street 1:2101 WAUKEGAN RD
Practice Address - Street 2:100
Practice Address - City:BANNOCKBURN
Practice Address - State:IL
Practice Address - Zip Code:60015-1836
Practice Address - Country:US
Practice Address - Phone:847-236-1194
Practice Address - Fax:847-236-1195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-09
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.007835111N00000X
225100000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty