Provider Demographics
NPI:1326344383
Name:LAKE MICHIGAN WELLNESS PLLC
Entity Type:Organization
Organization Name:LAKE MICHIGAN WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:STECK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-399-2984
Mailing Address - Street 1:4230 ELIZABETH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-5616
Mailing Address - Country:US
Mailing Address - Phone:616-399-2984
Mailing Address - Fax:
Practice Address - Street 1:513 E 8TH ST
Practice Address - Street 2:SUITE 12
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3765
Practice Address - Country:US
Practice Address - Phone:616-494-0204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008711111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950G011540OtherBCBS
MI950G011540OtherBCBS