LIFESTYLE REJUVENATION MEDICAL GROUP PLLC (NPI# 1134781974) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1134781974 |
| Entity Type | Organization |
| Organization Name | LIFESTYLE REJUVENATION MEDICAL GROUP PLLC |
| Practice Address |
1740 E 55th Street Chicago IL 60615 |
| Mailing Address |
1740 E 55th St Chicago IL 60615-5966 |
| Practice Telephone | 7736679053 |
| Mailing Telephone | 7736679053 |
| Enumeration Date | 2019-07-02 |
| Last Update Date | 2020-05-29 |
| Authorized Official Name | DR. ROBERT VAN HIGGINBOTTOM (CEO) |
| Authorized Official Telephone | 7736679053 |
| Authorized Official Credential | DC |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 111N00000X | Chiropractor | Chiropractic Providers | ||
| N | 111NR0400X |
Chiropractor Specialization: Rehabilitation |
Chiropractic Providers | ||
| N | 261QH0100X |
Clinic/Center Specialization: Health Service |
Ambulatory Health Care Facilities | ||
| N | 261QM2500X |
Clinic/Center Specialization: Medical Specialty |
Ambulatory Health Care Facilities | ||
| N | 261QP2000X |
Clinic/Center Specialization: Physical Therapy |
Ambulatory Health Care Facilities | ||
| N | 261QP2300X |
Clinic/Center Specialization: Primary Care |
Ambulatory Health Care Facilities | ||
| N | 261QP3300X |
Clinic/Center Specialization: Pain |
Ambulatory Health Care Facilities | ||
| N | 261QR0200X |
Clinic/Center Specialization: Radiology |
Ambulatory Health Care Facilities | ||
| N | 261QR0400X |
Clinic/Center Specialization: Rehabilitation |
Ambulatory Health Care Facilities | ||
| N | 261QR0800X |
Clinic/Center Specialization: Recovery Care |
Ambulatory Health Care Facilities | ||
| N | 302R00000X | Health Maintenance Organization | Managed Care Organizations | ||
| N | 305R00000X | Preferred Provider Organization | Managed Care Organizations | ||
| N | 305S00000X | Point of Service | Managed Care Organizations | ||
| N | 332B00000X | Durable Medical Equipment & Medical Supplies | Suppliers | ||
| Y | 261QM1300X |
Clinic/Center Specialization: Multi-Specialty |
Ambulatory Health Care Facilities |
| Address | Telephone Number | Fax Number |
|---|---|---|
| 1746 E 55th St, Chicago, IL 606155966 | 7736679053 |
| Street Address |
1740 E 55TH STREET |
| City | CHICAGO |
| State | IL |
| Zip Code | 60615 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1578170221 | Cook County | Technician, Other | 430 East 51st Pl, Chicago, IL 60615 | 2020-09-28 |
| 1700498326 | Connie Frances Davis | Massage Therapist | 5481 S. Cornell, Chicago, IL 60615 | 2020-08-17 |
| 1275007767 | Michelle Alyse Costello | Social Worker | 1225 E 53rd St, Suite 606, Chicago, IL 60615 | 2019-01-17 |
| 1194207522 | Cindy Louise Lys | Social Worker | 1525 E 53rd Street Suite 516-4, Chicago, IL 60615 | 2018-09-01 |
| 1861983660 | Pranusha Pinna | Student in an Organized Health Care Education/Training Program | 1850 W. Harrison St., Chicago, IL 60615 | 2018-05-29 |
| 1528577632 | Jonah Waseberg | Counselor | 1100 E.55th St, Chicago, IL 60615 | 2017-09-21 |
| 1710404496 | Tawann Jackson | Psychologist | 360 Blair Lane, Door 13, Bolingbrook, IL 60615 | 2017-08-24 |
| 1194259069 | Molly Kachale Netter | Nurse Practitioner | 1554 E 55th St., Chicago, IL 60615 | 2017-04-17 |
| 1205387990 | Kirk Remon Riddle | Counselor | 1525 E. 53rd Street, Suite 425, Chicago, IL 60615 | 2016-10-18 |
| 1326598319 | Highland Park Cvs, L.L.C. | Durable Medical Equipment & Medical Supplies | 1346 E 53rd St., Chicago, IL 60615 | 2016-10-13 |
| Find all providers in zip 60615 | ||||
| Taxonomy Code | 261QM1300X |
| Grouping | Ambulatory Health Care Facilities |
| Classification | Clinic/Center |
| Specialization | Multi-Specialty |
| Definition to come... |
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| 1104460922 | Infinite Care Home Physicians LLC | Clinic/Center | 6044 N Nassau Ave, Chicago, IL 60631-2649 | 2019-11-05 |
| 1962051607 | Wilkes Post Acute Care Inc | Clinic/Center | 400 W 76th St Ste 303, Chicago, IL 60620-1640 | 2019-09-05 |
| 1861964959 | Midway Medical | Clinic/Center | 2 W 103rd St, Chicago, IL 60628-2619 | 2018-12-30 |
| 1043727571 | The Board of Trustees of The University of Illinois | Clinic/Center | 835 S. Wolcott, Suite E-144; Mc 684, Chicago, IL 60612 | 2018-01-05 |
| 1386099562 | Healthworks Medical Group of Illinois S C | Clinic/Center | Gem Building 723, 1st Floor, Touhy & Mt Prospect Rd, Chicago, IL 60666 | 2016-04-26 |
| 1235584475 | Healthworks Medical Group of Illinois S C | Clinic/Center | Terminal 3, K19 Concourse, Ramp Level Rm 100, Touhy & Mt Prospect Rd, Chicago, IL 60666 | 2016-04-25 |
| 1689904039 | Prime Care Medical and Physical Therapy Centers, S.c. | Clinic/Center | 1719 W 18th St, Chicago, IL 60608-1913 | 2010-01-07 |
| 1790938249 | Healing Hands Resource Center | Clinic/Center | 3143 W Douglas Blvd, Chicago, IL 60623-1816 | 2008-10-28 |
| 1770739591 | Alivio Medical Center Inc | Clinic/Center | 3120 S Kostner Ave, Chicago, IL 60623-4842 | 2008-08-12 |
| Find all providers in CHICAGO | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.