Healthcare Provider Details

I. General information

NPI: 1174534580
Provider Name (Legal Business Name): LIFELINE CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3486 W. VOLLMER
OLYMPIA FIELDS IL
60461
US

IV. Provider business mailing address

3486 W. VOLLMER
OLYMPIA FIELDS IL
60461
US

V. Phone/Fax

Practice location:
  • Phone: 708-481-5444
  • Fax: 708-585-6226
Mailing address:
  • Phone: 708-481-5444
  • Fax: 708-585-6226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARK LAGERKVIST
Title or Position: PRESIDENT
Credential: D.C.
Phone: 708-481-5444