Provider Demographics
NPI:1558411074
Name:LAKE MOUNTAIN CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:LAKE MOUNTAIN CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:702-293-4488
Mailing Address - Street 1:1252 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89005-2745
Mailing Address - Country:US
Mailing Address - Phone:702-293-4488
Mailing Address - Fax:702-293-4487
Practice Address - Street 1:1252 WYOMING ST
Practice Address - Street 2:
Practice Address - City:BOULDER CITY
Practice Address - State:NV
Practice Address - Zip Code:89005-2745
Practice Address - Country:US
Practice Address - Phone:702-293-4488
Practice Address - Fax:702-293-4487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB00852111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV37829Medicare ID - Type Unspecified