Provider Demographics
NPI:1730197708
Name:LANGE, JEFFREY (DC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:LANGE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-1636
Mailing Address - Country:US
Mailing Address - Phone:618-524-7575
Mailing Address - Fax:
Practice Address - Street 1:810 MARKET ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-1636
Practice Address - Country:US
Practice Address - Phone:618-524-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007962111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038007962Medicaid
IL06422045OtherBLUE CROSS/BLUE SHIELD
IL06422045OtherBLUE CROSS/BLUE SHIELD