Provider Demographics
NPI:1710156443
Name:NORTHERN LAKES CHIROPRACTIC CLINIC, P.C.
Entity Type:Organization
Organization Name:NORTHERN LAKES CHIROPRACTIC CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEISY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-265-1900
Mailing Address - Street 1:30544 HIGHWAY 200 STE 330
Mailing Address - Street 2:
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852-5005
Mailing Address - Country:US
Mailing Address - Phone:208-265-1900
Mailing Address - Fax:208-227-8313
Practice Address - Street 1:30544 HIGHWAY 200 STE 330
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-5005
Practice Address - Country:US
Practice Address - Phone:208-265-1900
Practice Address - Fax:208-227-8313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1250111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty