Provider Demographics
NPI:1720324742
Name:LYSIAK, ROGER EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:EDWARD
Last Name:LYSIAK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:ROGER
Other - Middle Name:EDWARD
Other - Last Name:LYSIAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:677 N 36TH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4475
Mailing Address - Country:US
Mailing Address - Phone:765-346-3310
Mailing Address - Fax:
Practice Address - Street 1:677 N 36TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4475
Practice Address - Country:US
Practice Address - Phone:765-346-3310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000790A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor