Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 038012580 | IL |
N | 111NR0400X | Rehabilitation Chiropractor | 038012580 | IL |
N | 111NS0005X | Chiropractic Sports Physician | 038012580 | IL |
N | 111NX0100X | Occupational Health | 038012580 | IL |
NPI | 1508289745 |
---|---|
Provider Name | Dr. Peter Neofotistos |
First Address | Burr Ridge, IL 60527-4526 |
Second Address | Chicago Heights, IL 60411 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2014 |
Last Update Date | 01/09/2021 |