Provider Demographics
NPI:1669193793
Name:LAKE AND LEAF CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:LAKE AND LEAF CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:JON
Authorized Official - Last Name:GORMANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-257-2300
Mailing Address - Street 1:12818 LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045
Mailing Address - Country:US
Mailing Address - Phone:651-257-2300
Mailing Address - Fax:651-257-2333
Practice Address - Street 1:12818 LAKE BLVD
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045
Practice Address - Country:US
Practice Address - Phone:651-257-2300
Practice Address - Fax:651-257-2333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-07
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center