| Doctor Name: | DR. GLEN JOHN NISIVOCCIA |
| NPI Number: | 1689684979 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | D C |
| License Number: | 038004843 |
| Business Practice Address: | 19600 La Grange Rd Mokena, IL - 604489321 |
| Business Phone Number: | 7084783000 |
| Business Fax Number: | 7084783007 |
| Mailing Address: | 13129 Hidden Valley Dr, HOMER GLEN |
| State: | IL |
| Postal Code: | 604918486 |
| Phone Number: | 7083018723 |
| Fax Number: | |
| NPI Enumeration Date: | 08/09/2006 |
| NPI Last Update Date: | 06/17/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 111N00000X |
| License Number: | 038004843 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Chiropractic Providers |
| Taxonomy Classification: | Chiropractor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider qualified by a Doctor of Chiropractic (D.C.), licensed by the State and who practices chiropractic medicine -that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems. |