Provider Demographics
NPI:1891230447
Name:LAKE, REBECCA (DC)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3865 WOODLAND AVE
Mailing Address - Street 2:APT. 10
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-1986
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:974 73RD ST
Practice Address - Street 2:#40
Practice Address - City:WINDSOR HEIGHTS
Practice Address - State:IA
Practice Address - Zip Code:50324-1024
Practice Address - Country:US
Practice Address - Phone:309-644-0153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083854111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor