Provider Demographics
NPI:1285642256
Name:JEFFREY DON LANGE
Entity Type:Organization
Organization Name:JEFFREY DON LANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:LANGE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-524-7575
Mailing Address - Street 1:810 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-1636
Mailing Address - Country:US
Mailing Address - Phone:618-524-7575
Mailing Address - Fax:618-524-7262
Practice Address - Street 1:810 MARKET ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-1636
Practice Address - Country:US
Practice Address - Phone:618-524-7575
Practice Address - Fax:618-524-7262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007962111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL06422045OtherBLUE CROSS/BLUE SHIELD
IL038007962Medicaid
U61765Medicare UPIN
IL038007962Medicaid