Provider Demographics
NPI:1073146692
Name:QUAD CITIES REGENERATIVE MEDICINE, LLC
Entity Type:Organization
Organization Name:QUAD CITIES REGENERATIVE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-502-9513
Mailing Address - Street 1:4101 JOHN DEERE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6790
Mailing Address - Country:US
Mailing Address - Phone:309-581-2999
Mailing Address - Fax:
Practice Address - Street 1:4101 JOHN DEERE RD STE 2
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6790
Practice Address - Country:US
Practice Address - Phone:309-581-2999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty