Provider Demographics
NPI:1033125240
Name:JENNIFER LIDSTROM MS DC PC
Entity Type:Organization
Organization Name:JENNIFER LIDSTROM MS DC PC
Other - Org Name:LAKESIDE SPORTS CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LIDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-896-8446
Mailing Address - Street 1:19924 JETTON RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-8253
Mailing Address - Country:US
Mailing Address - Phone:704-896-8446
Mailing Address - Fax:704-896-8495
Practice Address - Street 1:19924 JETTON RD STE 101
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-8253
Practice Address - Country:US
Practice Address - Phone:704-896-8446
Practice Address - Fax:704-896-8495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3249111N00000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89085RMMedicaid
U93917Medicare UPIN
24573364Medicare ID - Type Unspecified