Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 038-007499 | IL |
N | 111NX0800X | Chiropractor Orthopedic Specialist | 038-007499 | IL |
NPI | 1518971886 |
---|---|
Provider Name | Scott Fonda |
First Address | Westmont, IL 60559-1132 |
Second Address | Westmont, IL 60559-1132 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/07/2006 |
Last Update Date | 16/11/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
038007499 | (05) | IL |
U83136 | (02) |