Provider Demographics
NPI:1114104262
Name:LIFESTYLE CHIROPRACTIC PC
Entity Type:Organization
Organization Name:LIFESTYLE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:HIGGINBOTTOM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-667-9053
Mailing Address - Street 1:1746 E 55TH STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615
Mailing Address - Country:US
Mailing Address - Phone:773-667-9053
Mailing Address - Fax:773-667-9084
Practice Address - Street 1:1746 E 55TH STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615
Practice Address - Country:US
Practice Address - Phone:773-667-9053
Practice Address - Fax:773-667-9084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL20995OtherMEDICARE GROUP #
IL20995OtherMEDICARE GROUP #
ILK10622Medicare PIN