Provider Demographics
NPI:1568635233
Name:NORTHLAKE MEDICAL
Entity Type:Organization
Organization Name:NORTHLAKE MEDICAL
Other - Org Name:CHIROPRACTIC & REHABILITATION
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:FORTUNATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-627-8602
Mailing Address - Street 1:3450 NORTHLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33403
Mailing Address - Country:US
Mailing Address - Phone:561-627-8602
Mailing Address - Fax:561-627-8603
Practice Address - Street 1:3450 NORTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:FL
Practice Address - Zip Code:33403
Practice Address - Country:US
Practice Address - Phone:561-627-8602
Practice Address - Fax:561-627-8603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center