Provider Demographics
NPI:1073814596
Name:LAKE HEALTH AND CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:LAKE HEALTH AND CHIROPRACTIC, PLLC
Other - Org Name:STOUT-FERGUSON CHIROPRACTIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER/CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMMIE
Authorized Official - Middle Name:JO
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-786-8834
Mailing Address - Street 1:1107 E. 13TH ST., SUITES A&B
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-7956
Mailing Address - Country:US
Mailing Address - Phone:918-786-8834
Mailing Address - Fax:918-786-6520
Practice Address - Street 1:1107 E. 13TH ST., SUITES A&B
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-7956
Practice Address - Country:US
Practice Address - Phone:918-786-8834
Practice Address - Fax:918-786-6520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-15
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3930111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty