Provider Demographics
NPI:1558546762
Name:LAKE COUNTY PHYSICAL MEDICINE LLC
Entity Type:Organization
Organization Name:LAKE COUNTY PHYSICAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:PARISSENTI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:906-632-8100
Mailing Address - Street 1:2243 ASHMUN ST
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-3704
Mailing Address - Country:US
Mailing Address - Phone:906-632-8100
Mailing Address - Fax:
Practice Address - Street 1:2243 ASHMUN ST
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-3704
Practice Address - Country:US
Practice Address - Phone:906-632-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008138111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty