Provider Demographics
NPI:1821178401
Name:FUKSA, SEBASTIAN R (DC)
Entity Type:Individual
Prefix:DR
First Name:SEBASTIAN
Middle Name:R
Last Name:FUKSA
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 1:4581 PRINCETON LANE
Mailing Address - Street 2:SUITE 119
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156
Mailing Address - Country:US
Mailing Address - Phone:847-669-6888
Mailing Address - Fax:847-669-8203
Practice Address - Street 1:4581 PRINCETON LN
Practice Address - Street 2:SUITE 119
Practice Address - City:LAKE IN THE HILLS
Practice Address - State:IL
Practice Address - Zip Code:60156
Practice Address - Country:US
Practice Address - Phone:847-669-6888
Practice Address - Fax:847-669-8203
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009936111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05632177OtherBCBS IL
ILK26692Medicare PIN