Provider Demographics
NPI:1295859569
Name:ROUND LAKE BEACH CHIROPRACTIC, S.C.
Entity Type:Organization
Organization Name:ROUND LAKE BEACH CHIROPRACTIC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-265-5600
Mailing Address - Street 1:36735 N IL ROUTE 83
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-9619
Mailing Address - Country:US
Mailing Address - Phone:847-265-5600
Mailing Address - Fax:847-245-4491
Practice Address - Street 1:36735 N IL ROUTE 83
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-9619
Practice Address - Country:US
Practice Address - Phone:847-265-5600
Practice Address - Fax:847-245-4491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006409111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU05485Medicare UPIN
IL932820Medicare ID - Type UnspecifiedMEDICARE #