Provider Demographics
NPI:1417939356
Name:WIGHT, LORI M (DC)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:M
Last Name:WIGHT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:LORI
Other - Middle Name:M
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:2230 W TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1545
Mailing Address - Country:US
Mailing Address - Phone:309-690-3322
Mailing Address - Fax:309-690-3323
Practice Address - Street 1:2230 W TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1545
Practice Address - Country:US
Practice Address - Phone:309-690-3322
Practice Address - Fax:309-690-3323
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008520111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor