Healthcare Provider Details

I. General information

NPI: 1255409645
Provider Name (Legal Business Name): AUSTIN LAKE CHIROPRACTIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8827 PORTAGE RD
PORTAGE MI
49002-6415
US

IV. Provider business mailing address

8827 PORTAGE RD.
PORTAGE MI
49002-6415
US

V. Phone/Fax

Practice location:
  • Phone: 269-324-1449
  • Fax: 269-323-2970
Mailing address:
  • Phone: 269-324-1449
  • Fax: 269-323-2970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301007246
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateMI

VIII. Authorized Official

Name: DR. MILTON DOUGLAS LYNES
Title or Position: CEO
Credential: DC
Phone: 269-324-1449