Provider Demographics
NPI:1215540463
Name:LAKE STATE CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:LAKE STATE CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-330-0352
Mailing Address - Street 1:4463 PENNY LN SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-9383
Mailing Address - Country:US
Mailing Address - Phone:269-330-0352
Mailing Address - Fax:
Practice Address - Street 1:2155 84TH ST SW STE 4
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-8259
Practice Address - Country:US
Practice Address - Phone:269-330-0352
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-27
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1972017481OtherINDIVIDUAL NPI
MI2301010620OtherCHIROPRACTIC LICENSE