Provider Demographics
NPI:1487311874
Name:LAVENDER, RUSTY
Entity type:Individual
Prefix:
First Name:RUSTY
Middle Name:
Last Name:LAVENDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 S RIDGEWAY RD
Mailing Address - Street 2:
Mailing Address - City:RINGWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60072-9610
Mailing Address - Country:US
Mailing Address - Phone:815-219-8033
Mailing Address - Fax:
Practice Address - Street 1:4310 S RIDGEWAY RD
Practice Address - Street 2:
Practice Address - City:RINGWOOD
Practice Address - State:IL
Practice Address - Zip Code:60072-9610
Practice Address - Country:US
Practice Address - Phone:815-219-8033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-21
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH13802111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor