Provider Demographics
NPI:1033448402
Name:LISLE CHIROPRACTIC CLINIC, LLC
Entity Type:Organization
Organization Name:LISLE CHIROPRACTIC CLINIC, LLC
Other - Org Name:HEALTHSOURCE OF LISLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:RUGINIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-963-1410
Mailing Address - Street 1:1025 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-4388
Mailing Address - Country:US
Mailing Address - Phone:630-963-1410
Mailing Address - Fax:630-963-1456
Practice Address - Street 1:1025 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-4388
Practice Address - Country:US
Practice Address - Phone:630-963-1410
Practice Address - Fax:630-963-1456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-003888111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT37242Medicare UPIN