Provider Demographics
NPI:1508859877
Name:LAKE, CHAD (DC)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:LAKE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5680 E SAGINAW HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-8102
Mailing Address - Country:US
Mailing Address - Phone:517-622-8552
Mailing Address - Fax:517-622-8591
Practice Address - Street 1:5680 E SAGINAW HWY
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-8102
Practice Address - Country:US
Practice Address - Phone:517-622-8552
Practice Address - Fax:517-622-8591
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008249111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4320240Medicaid
MI4320240Medicaid
MION22830Medicare PIN