Provider Demographics
NPI:1417044637
Name:LAKE NORMAN HEALTH AND WELLNESS, PA
Entity Type:Organization
Organization Name:LAKE NORMAN HEALTH AND WELLNESS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AKIBA
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-987-3993
Mailing Address - Street 1:18047 W CATAWBA AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-5664
Mailing Address - Country:US
Mailing Address - Phone:704-987-3993
Mailing Address - Fax:704-987-3991
Practice Address - Street 1:18047 W CATAWBA AVE
Practice Address - Street 2:SUITE E
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-5664
Practice Address - Country:US
Practice Address - Phone:704-987-3993
Practice Address - Fax:704-987-3991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3241111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903436Medicaid
NC2341240Medicare ID - Type UnspecifiedGROUP NUMBER