Provider Demographics
NPI:1952583015
Name:EAGLE LAKE CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:EAGLE LAKE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:256-582-4330
Mailing Address - Street 1:12844 US HIGHWAY 431 STE B
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-9312
Mailing Address - Country:US
Mailing Address - Phone:256-582-4330
Mailing Address - Fax:
Practice Address - Street 1:12844 US HIGHWAY 431 STE B
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-9312
Practice Address - Country:US
Practice Address - Phone:256-582-4330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2029111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1477694636Medicare UPIN