Provider Demographics
NPI:1235413048
Name:LAKE DRIVE CHIOPRACTIC CLINIC
Entity Type:Organization
Organization Name:LAKE DRIVE CHIOPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:J
Authorized Official - Last Name:MURRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-786-0670
Mailing Address - Street 1:8820 N HIGHWAY DR
Mailing Address - Street 2:
Mailing Address - City:CIRCLE PINES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-3907
Mailing Address - Country:US
Mailing Address - Phone:763-786-0670
Mailing Address - Fax:762-786-6423
Practice Address - Street 1:8820 N HIGHWAY DR
Practice Address - Street 2:
Practice Address - City:CIRCLE PINES
Practice Address - State:MN
Practice Address - Zip Code:55014-3907
Practice Address - Country:US
Practice Address - Phone:763-786-0670
Practice Address - Fax:762-786-6423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1497111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350001465Medicare PIN
MNT39810Medicare UPIN