Provider Demographics
NPI:1366681025
Name:MARQUE MEDICOS ARCHER, LLC
Entity type:Organization
Organization Name:MARQUE MEDICOS ARCHER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALLERY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-283-3131
Mailing Address - Street 1:4176 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2161
Mailing Address - Country:US
Mailing Address - Phone:773-283-3131
Mailing Address - Fax:773-283-3610
Practice Address - Street 1:4195 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-1849
Practice Address - Country:US
Practice Address - Phone:773-283-3131
Practice Address - Fax:773-283-3610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008088111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty