Provider Demographics
NPI:1669894457
Name:LAKE NORMAN CHIROPRACTIC CENTER, PA
Entity type:Organization
Organization Name:LAKE NORMAN CHIROPRACTIC CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-664-3455
Mailing Address - Street 1:612 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-2312
Mailing Address - Country:US
Mailing Address - Phone:704-664-3455
Mailing Address - Fax:704-664-2827
Practice Address - Street 1:612 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2312
Practice Address - Country:US
Practice Address - Phone:704-664-3455
Practice Address - Fax:704-664-2827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-13
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4232111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1093012692Medicare PIN