Healthcare Provider Details

I. General information

NPI: 1366998874
Provider Name (Legal Business Name): LAKESIDE SPINE AND WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1828 W WILSON AVE
CHICAGO IL
60640-5204
US

IV. Provider business mailing address

PO BOX 180021
CHICAGO IL
60618-0509
US

V. Phone/Fax

Practice location:
  • Phone: 773-828-9506
  • Fax: 773-439-5168
Mailing address:
  • Phone: 773-767-3822
  • Fax: 773-337-9106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038013006
License Number StateIL

VIII. Authorized Official

Name: DR. ANDREW M KIPER
Title or Position: OWNER
Credential: DC
Phone: 773-828-9506