Provider Demographics
NPI:1891917795
Name:DAVIS, LOREN (DC)
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:
Last Name:DAVIS
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 1:16622 W. 159TH ST.
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-8015
Mailing Address - Country:US
Mailing Address - Phone:815-838-7746
Mailing Address - Fax:815-838-5090
Practice Address - Street 1:16622 W. 159TH ST.
Practice Address - Street 2:SUITE 500
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-8015
Practice Address - Country:US
Practice Address - Phone:815-838-7746
Practice Address - Fax:815-838-5090
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008320111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00864465OtherPTAN
9932868OtherBLUE CROSS BLUE SHIELD
172851Medicare PIN
U76926Medicare UPIN