Basic Information
Provider Information | |||||||||
NPI: | 1679988018 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEE | ||||||||
FirstName: | NOLAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.C. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 222 W ONTARIO ST STE 310 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606543621 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3128809697 | ||||||||
FaxNumber: | 7735856201 | ||||||||
Practice Location | |||||||||
Address1: | 222 W ONTARIO ST STE 310 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 60654 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3128809697 | ||||||||
FaxNumber: | 7735856201 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2014 | ||||||||
LastUpdateDate: | 09/14/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 038.012631 | IL | N |   | Chiropractic Providers | Chiropractor |   | 208D00000X | 038012631 | IL | Y |   | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.