Provider Demographics
NPI:1912156795
Name:LAKEVILLE COMMUNITY CHIROPRACTIC
Entity Type:Organization
Organization Name:LAKEVILLE COMMUNITY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-360-3483
Mailing Address - Street 1:15677 HAYES TRL
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7137
Mailing Address - Country:US
Mailing Address - Phone:952-432-2313
Mailing Address - Fax:
Practice Address - Street 1:17305 CEDAR AVE S
Practice Address - Street 2:SUITE 250
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-3901
Practice Address - Country:US
Practice Address - Phone:612-360-3483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKEVILLE COMMUNITY CHIROPRACTIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5097111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty