Provider Demographics
NPI:1184881344
Name:LAKESHORE CHIROPRACTIC AND SPORTS REHABILITATION PLLC
Entity type:Organization
Organization Name:LAKESHORE CHIROPRACTIC AND SPORTS REHABILITATION PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:231-237-0665
Mailing Address - Street 1:1302 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1608
Mailing Address - Country:US
Mailing Address - Phone:231-237-0665
Mailing Address - Fax:231-237-0672
Practice Address - Street 1:1302 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1608
Practice Address - Country:US
Practice Address - Phone:231-237-0665
Practice Address - Fax:231-237-0672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004616111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1408604Medicaid
MI950A510420OtherBCBSM OF MICHIGAN
MI950A550050OtherBCBS
MI950A550050OtherBCBS