Healthcare Provider Details

I. General information

NPI: 1902918519
Provider Name (Legal Business Name): ANDREW EDGAR LAKE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
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
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1657
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: