Provider Demographics
NPI:1447847371
Name:MONTALVO, ANDRETTI (DC)
Entity type:Individual
Prefix:DR
First Name:ANDRETTI
Middle Name:
Last Name:MONTALVO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 N LAKE SHORE DR APT 2220
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-7869
Mailing Address - Country:US
Mailing Address - Phone:864-401-2113
Mailing Address - Fax:
Practice Address - Street 1:561 W DIVERSEY PKWY STE 221
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1682
Practice Address - Country:US
Practice Address - Phone:864-401-2113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-27
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013588111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor