# LIFESTYLE REJUVENATION MEDICAL GROUP PLLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1134781974
- **Authorized official:** DR. ROBERT VAN HIGGINBOTTOM DC (CEO)
- **Authorized official phone:** (773) 667-9053

## Contact information

- **Practice address:** 1740 E 55TH STREET, CHICAGO, IL 60615
- **Practice address phone:** (773) 667-9053
- **Mailing address:** 1740 E 55TH ST, CHICAGO, IL 60615-5966
- **Mailing address phone:** (773) 667-9053

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 111N00000X | Chiropractor | — | NULL | — |
| 111N00000X | Chiropractor | — | — | — |
| 111NR0400X | Rehabilitation Chiropractor | — | NULL | — |
| 111NR0400X | Rehabilitation Chiropractor | — | — | — |
| 261QH0100X | Health Service Clinic/Center | — | NULL | — |
| 261QM1300X | Multi-Specialty Clinic/Center | — | NULL | Yes |
| 261QM2500X | Medical Specialty Clinic/Center | — | NULL | — |
| 261QP2000X | Physical Therapy Clinic/Center | — | NULL | — |
| 261QP2300X | Primary Care Clinic/Center | — | NULL | — |
| 261QP3300X | Pain Clinic/Center | — | NULL | — |
| 261QR0200X | Radiology Clinic/Center | — | NULL | — |
| 261QR0400X | Rehabilitation Clinic/Center | — | NULL | — |
| 261QR0800X | Recovery Care Clinic/Center | — | NULL | — |
| 302R00000X | Health Maintenance Organization | — | NULL | — |
| 305R00000X | Preferred Provider Organization | — | NULL | — |
| 305S00000X | Point of Service | — | NULL | — |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |

## Other

- **Enumeration date:** 07/02/2019
- **Last updated:** 05/29/2020