Provider Demographics
NPI:1780196659
Name:LAKE COUNTRY FAMILY CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:LAKE COUNTRY FAMILY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:706-991-5348
Mailing Address - Street 1:112 HARMONY XING STE 1
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-9536
Mailing Address - Country:US
Mailing Address - Phone:706-991-5348
Mailing Address - Fax:
Practice Address - Street 1:112 HARMONY XING STE 1
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-9536
Practice Address - Country:US
Practice Address - Phone:706-991-5348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty