Provider Demographics
NPI:1356576060
Name:LAKES AREA CHIROPRACTIC CLINIC LLC
Entity type:Organization
Organization Name:LAKES AREA CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-257-3900
Mailing Address - Street 1:12814 LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045-9345
Mailing Address - Country:US
Mailing Address - Phone:651-257-3900
Mailing Address - Fax:651-257-3932
Practice Address - Street 1:12814 LAKE BLVD
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045-9345
Practice Address - Country:US
Practice Address - Phone:651-257-3900
Practice Address - Fax:651-257-3932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-26
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3423111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty