Provider Demographics
NPI:1750664215
Name:LIFESTYLE FAMILY CHIROPRACTIC, P.C.
Entity Type:Organization
Organization Name:LIFESTYLE FAMILY CHIROPRACTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCSP
Authorized Official - Phone:815-895-3200
Mailing Address - Street 1:1101 DEKALB AVE
Mailing Address - Street 2:SUITE #1
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3305
Mailing Address - Country:US
Mailing Address - Phone:815-895-3200
Mailing Address - Fax:
Practice Address - Street 1:1101 DEKALB AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3305
Practice Address - Country:US
Practice Address - Phone:815-895-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-007533111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU58744Medicare UPIN