Healthcare Provider Details

I. General information

NPI: 1346385143
Provider Name (Legal Business Name): LAKE CHIROPRACTIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40031 US HIGHWAY 160 SUITE C
BAYFIELD CO
81122-8746
US

IV. Provider business mailing address

PO BOX 1745
BAYFIELD CO
81122-1745
US

V. Phone/Fax

Practice location:
  • Phone: 970-884-1072
  • Fax: 970-884-1074
Mailing address:
  • Phone: 970-884-1072
  • Fax: 970-884-1074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5818
License Number StateCO

VIII. Authorized Official

Name: ANDREW E LAKE
Title or Position: PRESIDENT
Credential: D.C.
Phone: 970-884-1072