Provider Demographics
NPI:1285925461
Name:NAM, ILL (DC)
Entity type:Individual
Prefix:
First Name:ILL
Middle Name:
Last Name:NAM
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 1:505 S. DECATUR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107
Mailing Address - Country:US
Mailing Address - Phone:702-870-7582
Mailing Address - Fax:702-870-7583
Practice Address - Street 1:505 S. DECATUR BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107
Practice Address - Country:US
Practice Address - Phone:702-870-7582
Practice Address - Fax:702-870-7583
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-22
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB01417111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor