Provider Demographics
NPI:1437371200
Name:LAKESHORE CHIROPRACTIC, S.C.
Entity Type:Organization
Organization Name:LAKESHORE CHIROPRACTIC, S.C.
Other - Org Name:LAKESHORE CHIROPRACTIC, S.C.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-793-4498
Mailing Address - Street 1:3009 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-1926
Mailing Address - Country:US
Mailing Address - Phone:920-793-4498
Mailing Address - Fax:920-553-4499
Practice Address - Street 1:3009 FOREST AVE
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-1926
Practice Address - Country:US
Practice Address - Phone:920-793-4498
Practice Address - Fax:920-553-4499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3351-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU62164Medicare UPIN