Provider Demographics
NPI:1962053264
Name:CHICAGO BONE & JOINT CLINIC LLC
Entity type:Organization
Organization Name:CHICAGO BONE & JOINT CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER, FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:VALLANDIGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:312-972-6017
Mailing Address - Street 1:PO BOX 11040
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-0001
Mailing Address - Country:US
Mailing Address - Phone:312-972-6017
Mailing Address - Fax:
Practice Address - Street 1:6457 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5148
Practice Address - Country:US
Practice Address - Phone:312-972-6017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1952341596Medicaid