Provider Demographics
NPI:1164431771
Name:STAKER CHIROPRACTIC LIFE CENTER P C
Entity Type:Organization
Organization Name:STAKER CHIROPRACTIC LIFE CENTER P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYCE
Authorized Official - Middle Name:CURTIS
Authorized Official - Last Name:STAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-232-6616
Mailing Address - Street 1:501 LARK ST
Mailing Address - Street 2:P. O. BOX 47
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2526
Mailing Address - Country:US
Mailing Address - Phone:630-232-6616
Mailing Address - Fax:630-232-6681
Practice Address - Street 1:501 LARK ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2526
Practice Address - Country:US
Practice Address - Phone:630-232-6616
Practice Address - Fax:630-232-6681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4522176OtherBLUE SHIELD GROUP NUMBER
IL511110Medicare PIN