Provider Demographics
NPI:1821526260
Name:LAKELAND CHIROPRACTIC PA
Entity Type:Organization
Organization Name:LAKELAND CHIROPRACTIC PA
Other - Org Name:LAKELAND CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANI
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-687-7029
Mailing Address - Street 1:14822 N HIGHWAY 41
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-8461
Mailing Address - Country:US
Mailing Address - Phone:208-687-7029
Mailing Address - Fax:
Practice Address - Street 1:14822 N HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-8461
Practice Address - Country:US
Practice Address - Phone:208-687-7029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-924261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
1881705366OtherMEDICAID, BLUE SHIELD OF IDAHO