Provider Demographics
NPI:1255409645
Name:AUSTIN LAKE CHIROPRACTIC INC.
Entity type:Organization
Organization Name:AUSTIN LAKE CHIROPRACTIC INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MILTON
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:LYNES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-324-1449
Mailing Address - Street 1:8827 PORTAGE RD.
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-6415
Mailing Address - Country:US
Mailing Address - Phone:269-324-1449
Mailing Address - Fax:269-323-2970
Practice Address - Street 1:8827 PORTAGE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-6415
Practice Address - Country:US
Practice Address - Phone:269-324-1449
Practice Address - Fax:269-323-2970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332B00000X
MI2301007246111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M24860Medicare ID - Type UnspecifiedM. DOUGLAS LYNES
MIU60913Medicare UPIN
MI6424410001Medicare NSC