Healthcare Provider Details

I. General information

NPI: 1669894457
Provider Name (Legal Business Name): LAKE NORMAN CHIROPRACTIC CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2014
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 N MAIN ST
MOORESVILLE NC
28115-2312
US

IV. Provider business mailing address

612 N MAIN ST
MOORESVILLE NC
28115-2312
US

V. Phone/Fax

Practice location:
  • Phone: 704-664-3455
  • Fax: 704-664-2827
Mailing address:
  • Phone: 704-664-3455
  • Fax: 704-664-2827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4232
License Number StateNC

VIII. Authorized Official

Name: JENNIFER LEIGH JENNINGS
Title or Position: OFFICE MANAGER
Credential:
Phone: 704-664-3455