Provider Demographics
NPI:1811268667
Name:LAKESIDE CHIROPRACTIC WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:LAKESIDE CHIROPRACTIC WELLNESS CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:ENOCH
Authorized Official - Last Name:CALLAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-401-8207
Mailing Address - Street 1:1208 KILLARNEY SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-8515
Mailing Address - Country:US
Mailing Address - Phone:678-644-1990
Mailing Address - Fax:866-248-6750
Practice Address - Street 1:3750 PALLADIAN VILLAGE DR
Practice Address - Street 2:SUITE 330
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-8200
Practice Address - Country:US
Practice Address - Phone:678-401-8207
Practice Address - Fax:866-248-6750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-24
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008802111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty