Provider Demographics
NPI:1417006859
Name:MESTDAGH, LAURIE ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:ROBERT
Last Name:MESTDAGH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-1070
Mailing Address - Country:US
Mailing Address - Phone:618-281-6167
Mailing Address - Fax:618-281-4444
Practice Address - Street 1:1550 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1070
Practice Address - Country:US
Practice Address - Phone:618-281-6167
Practice Address - Fax:618-281-4444
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009443111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038009443Medicaid
V05028Medicare UPIN
ILK17568Medicare PIN