Provider Demographics
NPI:1487018222
Name:LAKE CITY SPINE & INJURY, LLC
Entity Type:Organization
Organization Name:LAKE CITY SPINE & INJURY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-438-5524
Mailing Address - Street 1:2057 SW MAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0021
Mailing Address - Country:US
Mailing Address - Phone:386-438-5524
Mailing Address - Fax:
Practice Address - Street 1:2057 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0021
Practice Address - Country:US
Practice Address - Phone:386-438-5524
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE CITY SPINE & INJURY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9403111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty