Provider Demographics
NPI:1477679587
Name:LAGRANGE CHIROPRACTIC PSC
Entity type:Organization
Organization Name:LAGRANGE CHIROPRACTIC PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:LIDO
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PETRUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:502-222-0000
Mailing Address - Street 1:301 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031
Mailing Address - Country:US
Mailing Address - Phone:502-222-0000
Mailing Address - Fax:502-222-3488
Practice Address - Street 1:301 S 1ST ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031
Practice Address - Country:US
Practice Address - Phone:502-222-0000
Practice Address - Fax:502-222-3488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4315111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2438073000OtherPASSPORT ADVANTAGE
KY350048657OtherRAILROAD MEDICARE
KY0974279OtherAETNA
KY1140369OtherPASSPORT
KY9943660003OtherCIGNA
KY85036697Medicaid
KYU63869Medicare UPIN
KY9943660003OtherCIGNA