Provider Demographics
NPI:1639349327
Name:INDIAN LAKE CHIROPRACTIC CENTRE INC.
Entity Type:Organization
Organization Name:INDIAN LAKE CHIROPRACTIC CENTRE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:CERWINKSY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:937-843-5286
Mailing Address - Street 1:180 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OH
Mailing Address - Zip Code:43331
Mailing Address - Country:US
Mailing Address - Phone:937-843-5286
Mailing Address - Fax:937-843-5285
Practice Address - Street 1:180 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OH
Practice Address - Zip Code:43331
Practice Address - Country:US
Practice Address - Phone:937-843-5286
Practice Address - Fax:937-843-5285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH533111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9319661Medicare PIN