Provider Demographics
NPI:1093040578
Name:MYERS, LANCE AVERY (DC)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:AVERY
Last Name:MYERS
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 1:4921 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2275
Mailing Address - Country:US
Mailing Address - Phone:815-398-4004
Mailing Address - Fax:815-398-4005
Practice Address - Street 1:4921 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2275
Practice Address - Country:US
Practice Address - Phone:815-398-4004
Practice Address - Fax:815-398-4005
Is Sole Proprietor?:No
Enumeration Date:2009-10-16
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011531111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor