Provider Demographics
NPI:1669005013
Name:LAKESIDE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:LAKESIDE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAYNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOSSETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-657-8434
Mailing Address - Street 1:5024 GREEN BAY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1702
Mailing Address - Country:US
Mailing Address - Phone:262-657-8434
Mailing Address - Fax:262-657-8435
Practice Address - Street 1:5024 GREEN BAY RD STE 100
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1702
Practice Address - Country:US
Practice Address - Phone:262-657-8434
Practice Address - Fax:262-657-8435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty