Healthcare Provider Details

I. General information

NPI: 1558526210
Provider Name (Legal Business Name): HERBERT VINCENT LAKE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BERT VINCENT LAKE D.C., CNIM

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1052 E INDIAN SCHOOL RD
PHOENIX AZ
85014-4810
US

IV. Provider business mailing address

1442 E PARKVIEW DR
GILBERT AZ
85295-6199
US

V. Phone/Fax

Practice location:
  • Phone: 602-279-0090
  • Fax: 602-279-6985
Mailing address:
  • Phone: 602-692-5116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5852
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: