Provider Demographics
NPI:1467500850
Name:LEBANON CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:LEBANON CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:FISCHER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-537-4407
Mailing Address - Street 1:110 W SAINT LOUIS ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IL
Mailing Address - Zip Code:62254-1559
Mailing Address - Country:US
Mailing Address - Phone:618-537-4407
Mailing Address - Fax:
Practice Address - Street 1:110 W SAINT LOUIS ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IL
Practice Address - Zip Code:62254-1559
Practice Address - Country:US
Practice Address - Phone:618-537-4407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL634840OtherMEDICARE
IL=========OtherTAX ID