Basic Information
| Provider Information | |||||||||
| NPI: | 1033239355 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOMA HEALTHCARE CENTER SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 W BUTTERFIELD RD | ||||||||
| Address2: | SUITE 315 | ||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601265068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305304500 | ||||||||
| FaxNumber: | 6308339680 | ||||||||
| Practice Location | |||||||||
| Address1: | 2052 N CLEVELAND AVE | ||||||||
| Address2: | GARDEN LEVEL | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606144505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305304500 | ||||||||
| FaxNumber: | 7732812226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 10/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | RUGG | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6305304500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 038007861 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 208888 | 01 | IL | MEDICARE PROVIDER NUMBER | OTHER |