Provider Demographics
NPI:1639627284
Name:LAKESIDE CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:LAKESIDE CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:501-825-7200
Mailing Address - Street 1:PO BOX 115
Mailing Address - Street 2:
Mailing Address - City:HIGDEN
Mailing Address - State:AR
Mailing Address - Zip Code:72067-0115
Mailing Address - Country:US
Mailing Address - Phone:501-825-7200
Mailing Address - Fax:
Practice Address - Street 1:5 SHILOH RD
Practice Address - Street 2:
Practice Address - City:HIGDEN
Practice Address - State:AR
Practice Address - Zip Code:72067-9521
Practice Address - Country:US
Practice Address - Phone:501-825-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-12
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1724261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center