Provider Demographics
NPI:1437145711
Name:LAKELAND CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:LAKELAND CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:CLIFFORD
Authorized Official - Last Name:LOF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-847-2631
Mailing Address - Street 1:119 GRAYSTONE PLZ
Mailing Address - Street 2:STE 110
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3034
Mailing Address - Country:US
Mailing Address - Phone:218-847-2631
Mailing Address - Fax:218-847-0048
Practice Address - Street 1:119 GRAYSTONE PLZ
Practice Address - Street 2:STE 110
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3034
Practice Address - Country:US
Practice Address - Phone:218-847-2631
Practice Address - Fax:218-847-0048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1603111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T65801Medicare UPIN