=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346385143
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE CHIROPRACTIC, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40031 US HIGHWAY 160 SUITE C
-----------------------------------------------------
City | BAYFIELD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81122-8746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-884-1072
-----------------------------------------------------
Fax | 970-884-1074
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1745
-----------------------------------------------------
City | BAYFIELD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81122-1745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-884-1072
-----------------------------------------------------
Fax | 970-884-1074
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ANDREW E LAKE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 970-884-1072
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 5818
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------