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General NPI Number Information
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NPI Number | 1548068869
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Entity Type | Organization
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Legal Business Name | LAKELIFE INTEGRATIVE HEALTH
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Dates
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Enumeration Date | 03/04/2025
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Last Update Date | 03/04/2025
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Provider Practice Location Address
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Address Line | 5862N STATE ROAD 70
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City | STONE LAKE
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State | WI
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Zip | 54876
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Country | US
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Telephone | 715-205-5560
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Fax |
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Provider Business Mailing Address
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Address Line | 16206 W STATE ROAD 70
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City | STONE LAKE
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State | WI
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Zip | 54876-1101
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Country | US
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Telephone | 715-205-5560
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TANAE BERG
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Credential | DC
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Telephone | 715-205-5560
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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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