Provider Demographics
NPI:1114049301
Name:LINCOLN CHIROPRACTIC OFFICE
Entity Type:Organization
Organization Name:LINCOLN CHIROPRACTIC OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANATULY
Authorized Official - Middle Name:
Authorized Official - Last Name:KANTAROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-674-2171
Mailing Address - Street 1:6600 N LINCOLN AV
Mailing Address - Street 2:S 215
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712
Mailing Address - Country:US
Mailing Address - Phone:847-674-2171
Mailing Address - Fax:
Practice Address - Street 1:6600 N LINCOLN AV
Practice Address - Street 2:S 215
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712
Practice Address - Country:US
Practice Address - Phone:847-674-2171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038005882111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T38758OtherMCARE UPIN
IL1682706OtherBCBS
IL038005882Medicaid
T38758OtherMCARE UPIN