Healthcare Provider Details

I. General information

NPI: 1578574604
Provider Name (Legal Business Name): MARK LAGERKVIST D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 08/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 ANGELA LN UNIT 19
CRYSTAL LAKE IL
60014-1075
US

IV. Provider business mailing address

2625 BUTTERFIELD RD STE 301N
OAK BROOK IL
60523-1234
US

V. Phone/Fax

Practice location:
  • Phone: 815-301-4200
  • Fax: 815-301-4203
Mailing address:
  • Phone: 630-320-6400
  • Fax: 630-701-1007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038-008544
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: