=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326656539
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE SQUARE CHIROPRACTIC, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2020
-----------------------------------------------------
Last Update Date | 07/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32629 BLOSSOM LN
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34788-3907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-326-2481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1010 RIVIERA DR
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34748-6742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-462-5773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | NATHANIEL BIEGLER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 352-326-2481
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------