Provider Demographics
NPI:1295279719
Name:REPAIR ROOM LLC
Entity type:Organization
Organization Name:REPAIR ROOM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-868-9609
Mailing Address - Street 1:500 DAVIS ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4668
Mailing Address - Country:US
Mailing Address - Phone:847-868-9609
Mailing Address - Fax:847-990-7944
Practice Address - Street 1:8150 MCCORMICK BLVD
Practice Address - Street 2:CONTINUUM GYM
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-2920
Practice Address - Country:US
Practice Address - Phone:847-868-9609
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.012514111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty