Provider Demographics
NPI:1225041122
Name:ENEVOLDSEN, LORI R (DC)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:R
Last Name:ENEVOLDSEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 JOLIET ST STE 104
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1995
Mailing Address - Country:US
Mailing Address - Phone:219-865-9917
Mailing Address - Fax:219-865-9957
Practice Address - Street 1:1100 JOLIET ST STE 104
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1995
Practice Address - Country:US
Practice Address - Phone:219-865-9917
Practice Address - Fax:219-865-9957
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001851A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor