Provider Demographics
NPI:1659514198
Name:LAKES FAMILY CHIROPRACTIC CLINIC P.A.
Entity Type:Organization
Organization Name:LAKES FAMILY CHIROPRACTIC CLINIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-784-2225
Mailing Address - Street 1:7771 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-1100
Mailing Address - Country:US
Mailing Address - Phone:651-784-2225
Mailing Address - Fax:651-784-2070
Practice Address - Street 1:7771 LAKE DR
Practice Address - Street 2:
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55014-1100
Practice Address - Country:US
Practice Address - Phone:651-784-2225
Practice Address - Fax:651-784-2070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-14
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3324261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1326169772OtherINDIVIDUAL NPI #
MN1326169772OtherINDIVIDUAL NPI #