Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0400X | Rehabilitation Chiropractor | 038007449 | IL |
NPI | 1114074168 |
---|---|
Provider Name | Dr. Ivan Robert Bracic |
First Address | Waukegan, IL 60085-3502 |
Second Address | Waukegan, IL 60085-3502 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2007 |
Last Update Date | 08/08/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
04932043 | BLUE CROSS BLUE SHIELD IL (01) | IL |
U49645 | (02) | IL |