MEDICARE: LIFESTYLE REJUVENATION MEDICAL GROUP PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	111N00000X	Chiropractor
2	111NR0400X	Rehabilitation Chiropractor
3	261QH0100X	Health Service Clinic/Center
4	261QM2500X	Medical Specialty Clinic/Center
5	261QP2000X	Physical Therapy Clinic/Center
6	261QP2300X	Primary Care Clinic/Center
7	261QP3300X	Pain Clinic/Center
8	261QR0200X	Radiology Clinic/Center
9	261QR0400X	Rehabilitation Clinic/Center
10	261QR0800X	Recovery Care Clinic/Center
11	302R00000X	Health Maintenance Organization
12	305R00000X	Preferred Provider Organization
13	305S00000X	Point of Service
14	332B00000X	Durable Medical Equipment & Medical Supplies
15	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1134781974
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESTYLE REJUVENATION MEDICAL GROUP PLLC

Provider Business Mailing Address
First Line	:	1740 E 55TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-5966
Country	:	US
Telephone Number	:	773-667-9053
Fax Number	:

Provider Business Practice Location Address
First Line	:	1740 E 55TH STREET
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615
Country	:	US
Telephone Number	:	773-667-9053
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. ROBERT VAN HIGGINBOTTOM
Credential	:	DC
Telephone Number	:	773-667-9053

Provider Enumeration Date	:	07/02/2019
Last Update Date	:	05/29/2020

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