Provider Demographics
NPI:1174516843
Name:BANDEROB, LYNN IRENE (DC)
Entity type:Individual
Prefix:DR
First Name:LYNN
Middle Name:IRENE
Last Name:BANDEROB
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:LYNN
Other - Middle Name:IRENE
Other - Last Name:L'ABBE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:3250 10TH AVE
Mailing Address - Street 2:STE. 1
Mailing Address - City:MARION
Mailing Address - State:IA
Mailing Address - Zip Code:52302-1507
Mailing Address - Country:US
Mailing Address - Phone:319-377-1234
Mailing Address - Fax:319-377-1930
Practice Address - Street 1:3250 10TH AVE
Practice Address - Street 2:STE. 1
Practice Address - City:MARION
Practice Address - State:IA
Practice Address - Zip Code:52302-1507
Practice Address - Country:US
Practice Address - Phone:319-377-1234
Practice Address - Fax:319-377-1930
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06492111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA49109OtherWELLMARK BLUECROSS BLUESH
IA0483743Medicaid
IAU91853Medicare UPIN
IAI17287Medicare PIN