Provider Demographics
NPI:1639407992
Name:TANNER, LUCAS AARON (DC)
Entity Type:Individual
Prefix:DR
First Name:LUCAS
Middle Name:AARON
Last Name:TANNER
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 1:21461 W ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60481-9613
Mailing Address - Country:US
Mailing Address - Phone:405-795-3332
Mailing Address - Fax:
Practice Address - Street 1:132 DEPOT ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:IL
Practice Address - Zip Code:60424-9401
Practice Address - Country:US
Practice Address - Phone:405-795-3332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-25
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038013364111N00000X
OK3963111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty