Provider Demographics
NPI:1225263601
Name:LAKE PLACID CHIROPRACTIC CLINIC, INC
Entity Type:Organization
Organization Name:LAKE PLACID CHIROPRACTIC CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:T
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:SR
Authorized Official - Credentials:DC
Authorized Official - Phone:863-699-6824
Mailing Address - Street 1:2411 US HIGHWAY 27 S
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-4943
Mailing Address - Country:US
Mailing Address - Phone:863-382-9632
Mailing Address - Fax:863-382-9632
Practice Address - Street 1:2411 US HIGHWAY 27 S
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-4943
Practice Address - Country:US
Practice Address - Phone:863-382-9632
Practice Address - Fax:863-382-9632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-28
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7378111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3814891-00Medicaid
FL55739OtherBC/BS
FLE0460Medicare PIN