Provider Demographics
NPI:1558526210
Name:LAKE, HERBERT VINCENT (DC)
Entity Type:Individual
Prefix:DR
First Name:HERBERT
Middle Name:VINCENT
Last Name:LAKE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:BERT
Other - Middle Name:VINCENT
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC, CNIM
Mailing Address - Street 1:1442 E PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-6199
Mailing Address - Country:US
Mailing Address - Phone:602-692-5116
Mailing Address - Fax:
Practice Address - Street 1:1052 E INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-4810
Practice Address - Country:US
Practice Address - Phone:602-279-0090
Practice Address - Fax:602-279-6985
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5852111N00000X
156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
No111N00000XChiropractic ProvidersChiropractor