Healthcare Provider Details

I. General information

NPI: 1962659417
Provider Name (Legal Business Name): LAKESIDE CHIROPRACTIC CLINIC,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 E SAGINAW RD SUITE 7
SANFORD MI
48657-9271
US

IV. Provider business mailing address

152 E SAGINAW RD SUITE 7
SANFORD MI
48657-9271
US

V. Phone/Fax

Practice location:
  • Phone: 989-687-9299
  • Fax: 989-687-6382
Mailing address:
  • Phone: 989-687-9299
  • Fax: 989-687-6382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301002908
License Number StateMI

VIII. Authorized Official

Name: DR. CEANN UNDINE BRANSON
Title or Position: OWNER
Credential: D.C.
Phone: 989-687-9299