Organization
LIFESTYLE REJUVENATION MEDICAL GROUP PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ROBERT VAN HIGGINBOTTOM DC (CEO)
(773) 667-9053
Entity
Organization
Contact information
Practice address
1740 E 55TH STREET, CHICAGO, IL 60615
(773) 667-9053
Mailing address
1740 E 55TH ST, CHICAGO, IL 60615-5966
(773) 667-9053
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
—
—
111NR0400X
Rehabilitation Chiropractor
—
—
261QH0100X
Health Service Clinic/Center
—
—
261QM1300X
Multi-Specialty Clinic/Center
Primary
—
—
261QM2500X
Medical Specialty Clinic/Center
—
—
261QP2000X
Physical Therapy Clinic/Center
—
—
261QP2300X
Primary Care Clinic/Center
—
—
261QP3300X
Pain Clinic/Center
—
—
261QR0200X
Radiology Clinic/Center
—
—
261QR0400X
Rehabilitation Clinic/Center
—
—
261QR0800X
Recovery Care Clinic/Center
—
—
302R00000X
Health Maintenance Organization
—
—
305R00000X
Preferred Provider Organization
—
—
305S00000X
Point of Service
—
—
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
Other
Enumeration date
07/02/2019
Last updated
05/29/2020
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