Provider Demographics
NPI:1326263591
Name:RONALD J LYSS DC
Entity Type:Organization
Organization Name:RONALD J LYSS DC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:LYSS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-736-5403
Mailing Address - Street 1:550 30TH AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-5975
Mailing Address - Country:US
Mailing Address - Phone:309-736-5403
Mailing Address - Fax:309-736-5406
Practice Address - Street 1:550 30TH AVE STE 3
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-5975
Practice Address - Country:US
Practice Address - Phone:309-736-5403
Practice Address - Fax:309-736-5406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL635280Medicare ID - Type UnspecifiedPROVIDER NUMBER