Provider Demographics
NPI:1174722433
Name:LAKE CHIROPRACTIC CENTER, PLLC
Entity type:Organization
Organization Name:LAKE CHIROPRACTIC CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:517-622-8552
Mailing Address - Street 1:914 CHARLEVOIX DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-2280
Mailing Address - Country:US
Mailing Address - Phone:517-622-8552
Mailing Address - Fax:517-622-8591
Practice Address - Street 1:914 CHARLEVOIX DR
Practice Address - Street 2:SUITE 120
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-2280
Practice Address - Country:US
Practice Address - Phone:517-622-8552
Practice Address - Fax:517-622-8591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008249111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty