Provider Demographics
NPI:1316951635
Name:INNER SPIRIT CHIROPRACTIC INC
Entity type:Organization
Organization Name:INNER SPIRIT CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DC
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LACKNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:3096-855-7777
Mailing Address - Street 1:4809 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5927
Mailing Address - Country:US
Mailing Address - Phone:309-685-5777
Mailing Address - Fax:309-685-5779
Practice Address - Street 1:4809 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5927
Practice Address - Country:US
Practice Address - Phone:309-685-5777
Practice Address - Fax:309-685-5779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7227304OtherBLUE CROSS BLUE SHIELD
IL7227304OtherBLUE CROSS BLUE SHIELD
IL628750Medicare ID - Type Unspecified