Provider Demographics
NPI:1316086267
Name:SUNSPOT SPINAL & SPORTS REHABILITATION
Entity type:Organization
Organization Name:SUNSPOT SPINAL & SPORTS REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:NATHAN
Authorized Official - Last Name:BODEM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-615-0656
Mailing Address - Street 1:PO BOX 2210
Mailing Address - Street 2:105 CANTERBURY LN
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-0138
Mailing Address - Country:US
Mailing Address - Phone:630-615-0656
Mailing Address - Fax:
Practice Address - Street 1:8224 LINDENWOOD LN
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-4105
Practice Address - Country:US
Practice Address - Phone:630-615-0656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042617979111N00000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty