Provider Demographics
NPI:1659619492
Name:HEALTHSOURCE OF LAKEVILLE
Entity Type:Organization
Organization Name:HEALTHSOURCE OF LAKEVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LAUER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-772-8723
Mailing Address - Street 1:15024 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-5085
Mailing Address - Country:US
Mailing Address - Phone:763-772-8723
Mailing Address - Fax:
Practice Address - Street 1:15024 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-5085
Practice Address - Country:US
Practice Address - Phone:763-772-8723
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4978111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty