Provider Demographics
NPI:1619174653
Name:LOLITA A. WILBURN D.C.P.C.
Entity Type:Organization
Organization Name:LOLITA A. WILBURN D.C.P.C.
Other - Org Name:BACK TO HEATLH CHIROPRACTIC-MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LOLITA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILBURN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-489-2225
Mailing Address - Street 1:12647 S JUSTINE ST
Mailing Address - Street 2:
Mailing Address - City:CALUMET PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60827-6009
Mailing Address - Country:US
Mailing Address - Phone:708-489-2225
Mailing Address - Fax:798-489-2610
Practice Address - Street 1:12647 S JUSTINE ST
Practice Address - Street 2:
Practice Address - City:CALUMET PARK
Practice Address - State:IL
Practice Address - Zip Code:60827-6009
Practice Address - Country:US
Practice Address - Phone:708-489-2225
Practice Address - Fax:798-489-2610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007208111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01622136OtherBLUE CROSSBLUE SHIELD
IL038007208Medicaid
IL038007208Medicaid