Provider Demographics
NPI:1023473386
Name:LIFETIME HEALTH CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:LIFETIME HEALTH CHIROPRACTIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC / PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:ENID
Authorized Official - Last Name:NIEVES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-713-1791
Mailing Address - Street 1:7501 N UNIVERSITY ST STE 220
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1258
Mailing Address - Country:US
Mailing Address - Phone:309-713-1791
Mailing Address - Fax:309-713-1791
Practice Address - Street 1:7501 N UNIVERSITY ST STE 220
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1258
Practice Address - Country:US
Practice Address - Phone:309-713-1791
Practice Address - Fax:309-713-1791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012736111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty