Provider Demographics
NPI:1356961007
Name:LAKE NORMAN INTEGRATIVE WELLNESS, LLC
Entity type:Organization
Organization Name:LAKE NORMAN INTEGRATIVE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AKIBA
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DNM
Authorized Official - Phone:704-658-7350
Mailing Address - Street 1:21000 TORRENCE CHAPEL RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-6874
Mailing Address - Country:US
Mailing Address - Phone:704-987-3993
Mailing Address - Fax:704-987-3991
Practice Address - Street 1:21000 TORRENCE CHAPEL RD STE 101
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-6874
Practice Address - Country:US
Practice Address - Phone:704-987-3993
Practice Address - Fax:704-987-3991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty