Provider Demographics
NPI:1962416867
Name:SDAO, NICOLE LEIGH (DC)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LEIGH
Last Name:SDAO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:LEIGH
Other - Last Name:BAHNUB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:455 W STEPHENSON ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-5001
Mailing Address - Country:US
Mailing Address - Phone:815-232-4217
Mailing Address - Fax:
Practice Address - Street 1:455 W STEPHENSON ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-5001
Practice Address - Country:US
Practice Address - Phone:815-232-4217
Practice Address - Fax:815-233-3379
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008743111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08925958OtherBLUE CROSS BLUE SHEILD #
IL350049409OtherMEDICARE RAILROAD #
IL36-3581491OtherICHP TAX I.D. #
IL75-3157454OtherPRACTICE CORP. TAX I.D.#
IL038-008743Medicaid
ILK13271OtherMEDICARE MEMBER #
IL75-3157454OtherPRACTICE CORP. TAX I.D.#
IL210593Medicare ID - Type Unspecified