Healthcare Provider Details

I. General information

NPI: 1609179456
Provider Name (Legal Business Name): LANDER FAMILY CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2010
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W DIVISION ST
COAL CITY IL
60416-1405
US

IV. Provider business mailing address

PO BOX 147
COAL CITY IL
60416-0147
US

V. Phone/Fax

Practice location:
  • Phone: 815-518-5228
  • Fax: 815-634-3188
Mailing address:
  • Phone: 815-518-5228
  • Fax: 815-634-3188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038009357
License Number StateIL

VIII. Authorized Official

Name: DR. BURGUNDY LYNN LANDER
Title or Position: OWNER
Credential: DC
Phone: 815-634-0126