Provider Demographics
NPI:1205265550
Name:LAKESIDE CHIROPRACTIC SPECIALISTS
Entity type:Organization
Organization Name:LAKESIDE CHIROPRACTIC SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEAKLEND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:402-697-7463
Mailing Address - Street 1:18017 OAK ST STE A
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-6024
Mailing Address - Country:US
Mailing Address - Phone:402-697-7463
Mailing Address - Fax:402-614-5174
Practice Address - Street 1:18017 OAK ST STE A
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-6024
Practice Address - Country:US
Practice Address - Phone:402-697-7463
Practice Address - Fax:402-892-1056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-07
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1351111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025234000Medicaid
NE09543OtherBLUE CROSS BLUE SHIELD OF NEBRASKA
NE09543OtherBLUE CROSS BLUE SHIELD OF NEBRASKA