Basic Information
Provider Information | |||||||||
NPI: | 1144372558 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE LIFEFORCE CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1300 W BELMONT AVE | ||||||||
Address2: | SUITE 407 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606573200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7738801363 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3111 DUNDEE RD | ||||||||
Address2: |   | ||||||||
City: | NORTHBROOK | ||||||||
State: | IL | ||||||||
PostalCode: | 600622402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475620840 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LARSON | ||||||||
AuthorizedOfficialFirstName: | CHAD | ||||||||
AuthorizedOfficialMiddleName: | C. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7738801363 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.C. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 38007103 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |   |
No ID Information.