Basic Information
Provider Information
NPI: 1003140567
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MURSU
FirstName: ANDREA
MiddleName: KAY
NamePrefix: MISS
NameSuffix:  
Credential: D.C.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2634 PATRIOT BLVD
Address2: SUITE B
City: GLENVIEW
State: IL
PostalCode: 600268024
CountryCode: US
TelephoneNumber: 8477305618
FaxNumber: 8477305673
Practice Location
Address1: 2634 PATRIOT BLVD
Address2: SUITE B
City: GLENVIEW
State: IL
PostalCode: 600268024
CountryCode: US
TelephoneNumber: 8477305618
FaxNumber: 8477305673
Other Information
ProviderEnumerationDate: 09/30/2009
LastUpdateDate: 01/13/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
111N00000X038011300ILY Chiropractic ProvidersChiropractor 

No ID Information.


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