Provider Demographics
NPI:1265610612
Name:LAKEVILLE CHIROPRACTIC, PC
Entity type:Organization
Organization Name:LAKEVILLE CHIROPRACTIC, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:TULLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:516-775-0778
Mailing Address - Street 1:516 LAKEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-3006
Mailing Address - Country:US
Mailing Address - Phone:516-775-0778
Mailing Address - Fax:516-775-0548
Practice Address - Street 1:516 LAKEVILLE RD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-3006
Practice Address - Country:US
Practice Address - Phone:516-775-0778
Practice Address - Fax:516-775-0548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYXVW401Medicare PIN