Provider Demographics
NPI:1336504471
Name:LA CLINICA SC
Entity type:Organization
Organization Name:LA CLINICA SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:JAO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:312-961-6611
Mailing Address - Street 1:PO BOX 4782
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-4782
Mailing Address - Country:US
Mailing Address - Phone:773-278-9525
Mailing Address - Fax:708-337-9135
Practice Address - Street 1:4123 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-2105
Practice Address - Country:US
Practice Address - Phone:773-278-9525
Practice Address - Fax:708-337-9135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042620268111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty