Provider Demographics
NPI:1700857802
Name:LACICH, MARK ALAN (DC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:LACICH
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 1:206 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-2350
Mailing Address - Country:US
Mailing Address - Phone:618-654-8989
Mailing Address - Fax:618-654-8655
Practice Address - Street 1:206 WALNUT ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-2350
Practice Address - Country:US
Practice Address - Phone:618-654-8989
Practice Address - Fax:618-654-8655
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL539216OtherHEALTHLINK
IL06032056OtherBLUE CROSS BLUE SHIELD
IL06032056OtherBLUE CROSS BLUE SHIELD
U94178Medicare UPIN