Provider Demographics
NPI:1134781974
Name:LIFESTYLE REJUVENATION MEDICAL GROUP PLLC
Entity type:Organization
Organization Name:LIFESTYLE REJUVENATION MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:HIGGINBOTTOM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-667-9053
Mailing Address - Street 1:1740 E 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-5966
Mailing Address - Country:US
Mailing Address - Phone:773-667-9053
Mailing Address - Fax:
Practice Address - Street 1:1740 E 55TH STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615
Practice Address - Country:US
Practice Address - Phone:773-667-9053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-02
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty