Provider Demographics
NPI:1194754895
Name:PSALTIS, NICK D (DC)
Entity type:Individual
Prefix:
First Name:NICK
Middle Name:D
Last Name:PSALTIS
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 1:4202 MARAY DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-4964
Mailing Address - Country:US
Mailing Address - Phone:815-397-3030
Mailing Address - Fax:815-395-8324
Practice Address - Street 1:4202 MARAY DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-4964
Practice Address - Country:US
Practice Address - Phone:815-397-3030
Practice Address - Fax:815-395-8324
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL790260Medicare ID - Type Unspecified
ILT39161Medicare UPIN