Provider Demographics
NPI:1861405987
Name:CARROLL, LANCE M (DC)
Entity type:Individual
Prefix:DR
First Name:LANCE
Middle Name:M
Last Name:CARROLL
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 1:4101 JOHN DEERE RD
Mailing Address - Street 2:STE 2
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6790
Mailing Address - Country:US
Mailing Address - Phone:309-581-2999
Mailing Address - Fax:309-581-2998
Practice Address - Street 1:4101 JOHN DEERE RD
Practice Address - Street 2:STE 2
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6790
Practice Address - Country:US
Practice Address - Phone:309-581-2999
Practice Address - Fax:309-581-2998
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009440111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
05732010OtherBCBS ID
071639OtherHEALTH ALLIANCE ID
05732010OtherBCBS ID