Provider Demographics
NPI:1952826778
Name:LAKE LIFE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:LAKE LIFE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRETTINGEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-562-8384
Mailing Address - Street 1:2940 N CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1388
Mailing Address - Country:US
Mailing Address - Phone:612-562-8384
Mailing Address - Fax:
Practice Address - Street 1:2940 N CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1388
Practice Address - Country:US
Practice Address - Phone:612-562-8384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6402111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty