Healthcare Provider Details

I. General information

NPI: 1639407992
Provider Name (Legal Business Name): LUCAS AARON TANNER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2009
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 DEPOT ST
GARDNER IL
60424-9401
US

IV. Provider business mailing address

21461 W ELMWOOD AVE
WILMINGTON IL
60481-9613
US

V. Phone/Fax

Practice location:
  • Phone: 405-795-3332
  • Fax:
Mailing address:
  • Phone: 405-795-3332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038013364
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3963
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: