Provider Demographics
NPI:1316111610
Name:CONNOLLY CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:CONNOLLY CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-574-0422
Mailing Address - Street 1:900 JORIE BLVD.
Mailing Address - Street 2:SUITE 104
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-3816
Mailing Address - Country:US
Mailing Address - Phone:630-574-0422
Mailing Address - Fax:630-574-1002
Practice Address - Street 1:900 JORIE BLVD.
Practice Address - Street 2:SUITE 104
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-3816
Practice Address - Country:US
Practice Address - Phone:630-574-0422
Practice Address - Fax:630-574-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211829Medicare PIN