Provider Demographics
NPI:1417133265
Name:LAKESIDE CHIROPRACTIC PC
Entity Type:Organization
Organization Name:LAKESIDE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:BOATRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:928-532-1225
Mailing Address - Street 1:PO BOX 3330
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-3330
Mailing Address - Country:US
Mailing Address - Phone:928-532-1225
Mailing Address - Fax:928-532-2276
Practice Address - Street 1:1640 E OLIVER PL
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-6117
Practice Address - Country:US
Practice Address - Phone:928-532-1225
Practice Address - Fax:928-532-2276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5129261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ69963Medicare PIN