Provider Demographics
NPI:1316655442
Name:VILLAVERDE, TIMOTHY RYAN
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RYAN
Last Name:VILLAVERDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 E JUNIPER LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-1453
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 W RAND RD STE A
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-1130
Practice Address - Country:US
Practice Address - Phone:847-499-1890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013903111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor