Provider Demographics
NPI:1417286139
Name:KERRY J. LAZENBY, PLLC
Entity Type:Organization
Organization Name:KERRY J. LAZENBY, PLLC
Other - Org Name:DR. KERRY J. LAZENBY, D.C.
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WANDRIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-729-7000
Mailing Address - Street 1:1243 E M 21
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-9038
Mailing Address - Country:US
Mailing Address - Phone:989-729-7000
Mailing Address - Fax:989-729-0842
Practice Address - Street 1:1243 E M 21
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-9038
Practice Address - Country:US
Practice Address - Phone:989-729-7000
Practice Address - Fax:989-729-0842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008232111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G810660OtherBLUE CROSS BLUE SHIELD
MI0G810660OtherBLUE CROSS BLUE SHIELD