Provider Demographics
NPI:1023125283
Name:HART, LISA A (DC LAC)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:HART
Suffix:
Gender:F
Credentials:DC LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:IL
Mailing Address - Zip Code:62016
Mailing Address - Country:US
Mailing Address - Phone:217-942-9069
Mailing Address - Fax:217-942-6769
Practice Address - Street 1:307 6TH ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:IL
Practice Address - Zip Code:62016
Practice Address - Country:US
Practice Address - Phone:217-942-9069
Practice Address - Fax:217-942-6769
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007515111N00000X
IL198000091171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03105605OtherBCBS BLUE CROSS BLUE SHIE
IL347060Medicare ID - Type Unspecified
U50256Medicare UPIN