Provider Demographics
NPI:1154831600
Name:LISLE CHIROPRATIC LLC
Entity Type:Organization
Organization Name:LISLE CHIROPRATIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:JUSTIN
Authorized Official - Last Name:MAITLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-235-6433
Mailing Address - Street 1:538 S ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-2960
Mailing Address - Country:US
Mailing Address - Phone:630-235-6433
Mailing Address - Fax:
Practice Address - Street 1:906 LACEY AVE
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1318
Practice Address - Country:US
Practice Address - Phone:630-963-1410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013131111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty