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General NPI Number Information
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NPI Number | 1215540463
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Entity Type | Organization
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Legal Business Name | LAKE STATE CHIROPRACTIC PLLC
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Dates
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Enumeration Date | 08/27/2020
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Last Update Date | 08/27/2020
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Provider Practice Location Address
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Address Line | 2155 84TH ST SW STE 4
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City | BYRON CENTER
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State | MI
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Zip | 49315-8259
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Country | US
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Telephone | 269-330-0352
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Fax |
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Provider Business Mailing Address
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Address Line | 4463 PENNY LN SW
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City | WYOMING
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State | MI
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Zip | 49418-9383
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Country | US
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Telephone | 269-330-0352
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Fax |
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Authorized Official
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Title or Position | OWNER/DOCTOR
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Name | DR. KEVIN JAMES SUNDBERG
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Credential | D.C.
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Telephone | 269-330-0352
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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