Provider Demographics
NPI:1346385143
Name:LAKE CHIROPRACTIC, PC
Entity Type:Organization
Organization Name:LAKE CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:E
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:970-884-1072
Mailing Address - Street 1:PO BOX 1745
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81122-1745
Mailing Address - Country:US
Mailing Address - Phone:970-884-1072
Mailing Address - Fax:970-884-1074
Practice Address - Street 1:40031 US HIGHWAY 160
Practice Address - Street 2:SUITE C
Practice Address - City:BAYFIELD
Practice Address - State:CO
Practice Address - Zip Code:81122-8746
Practice Address - Country:US
Practice Address - Phone:970-884-1072
Practice Address - Fax:970-884-1074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5818111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty