Provider Demographics
NPI:1699383273
Name:LAKE SUPERIOR CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:LAKE SUPERIOR CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEYAERT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:906-482-2400
Mailing Address - Street 1:45070 US HIGHWAY 41
Mailing Address - Street 2:
Mailing Address - City:CHASSELL
Mailing Address - State:MI
Mailing Address - Zip Code:49916-9168
Mailing Address - Country:US
Mailing Address - Phone:906-482-2400
Mailing Address - Fax:
Practice Address - Street 1:45070 US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:CHASSELL
Practice Address - State:MI
Practice Address - Zip Code:49916-9168
Practice Address - Country:US
Practice Address - Phone:906-482-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-20
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty