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General NPI Number Information
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NPI Number | 1578945390
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Entity Type | Organization
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Legal Business Name | LAKESIDE CHIROPRACTIC, PLLC
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Dates
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Enumeration Date | 06/29/2015
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Last Update Date | 06/29/2015
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Provider Practice Location Address
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Address Line | 1529 W ROGERS BLVD STE C
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City | SKIATOOK
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State | OK
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Zip | 74070-1086
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Country | US
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Telephone | 918-396-4433
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Fax | 918-396-0075
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Provider Business Mailing Address
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Address Line | 1529 W ROGERS BLVD STE C
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City | SKIATOOK
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State | OK
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Zip | 74070-1086
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Country | US
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Telephone | 918-396-4433
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Fax | 918-396-0075
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Authorized Official
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Title or Position | OWNER/DOCTOR
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Name | DR. ELIZABETH ANN GOODMAN
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Credential | D.C.
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Telephone | 918-396-4433
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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 | 4086
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License Number State | OK
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