Provider Demographics
NPI:1891764098
Name:JIMENEZ, MIGUEL A (DC, SA)
Entity type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:A
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:DC, SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8373
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-0373
Mailing Address - Country:US
Mailing Address - Phone:773-954-4438
Mailing Address - Fax:
Practice Address - Street 1:2548 S. BLUE ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608
Practice Address - Country:US
Practice Address - Phone:773-954-4438
Practice Address - Fax:773-823-1746
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238000485246ZC0007X
IL038-009097111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILV07979Medicare UPIN
ILK24153Medicare ID - Type Unspecified