Provider Demographics
NPI:1194300814
Name:AMBROSE, THOMAS JOHN (DC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:AMBROSE
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 1:1604 SIBLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-2231
Mailing Address - Country:US
Mailing Address - Phone:708-745-1086
Mailing Address - Fax:
Practice Address - Street 1:1604 SIBLEY BLVD
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-2231
Practice Address - Country:US
Practice Address - Phone:708-745-1086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013667111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor