1083881080 NPI number — LIFESTYLE CHIROPRACTIC & PROGRESSIVE REHAB

Table of content: (NPI 1083881080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083881080 NPI number — LIFESTYLE CHIROPRACTIC & PROGRESSIVE REHAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFESTYLE CHIROPRACTIC & PROGRESSIVE REHAB
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083881080
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13113 DELAWARE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROWN POINT
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46307-9703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-909-1518
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11065 BROADWAY
Provider Second Line Business Practice Location Address:
BLDG 12 STE A
Provider Business Practice Location Address City Name:
CROWN POINT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46307-7301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-909-1518
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MONDAY
Authorized Official First Name:
MITCHELL
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
312-909-1518

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  08002368A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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