Provider Demographics
NPI:1104043355
Name:LAKE STREET PAIN RELIEF CENTER, INC
Entity Type:Organization
Organization Name:LAKE STREET PAIN RELIEF CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ARELIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-990-8134
Mailing Address - Street 1:1304 E LAKE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1777
Mailing Address - Country:US
Mailing Address - Phone:612-827-7246
Mailing Address - Fax:612-827-8206
Practice Address - Street 1:515 W LAKE ST STE F
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2981
Practice Address - Country:US
Practice Address - Phone:612-827-7246
Practice Address - Fax:612-827-8206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty