Healthcare Provider Details

I. General information

NPI: 1548068869
Provider Name (Legal Business Name): LAKELIFE INTEGRATIVE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 03/04/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5862N STATE ROAD 70
STONE LAKE WI
54876
US

IV. Provider business mailing address

16206 W STATE ROAD 70
STONE LAKE WI
54876-1101
US

V. Phone/Fax

Practice location:
  • Phone: 715-205-5560
  • Fax:
Mailing address:
  • Phone: 715-205-5560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: TANAE BERG
Title or Position: OWNER
Credential: DC
Phone: 715-205-5560