Healthcare Provider Details

I. General information

NPI: 1154593937
Provider Name (Legal Business Name): LAKESIDE SPINE AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 NE 44TH ST STE 223
RENTON WA
98056-9035
US

IV. Provider business mailing address

2524 CAMAS AVE NE
RENTON WA
98056-2226
US

V. Phone/Fax

Practice location:
  • Phone: 206-852-7960
  • Fax:
Mailing address:
  • Phone: 206-852-7960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: ANDREW WINGER
Title or Position: OWNER
Credential: D.C.
Phone: 206-852-7960