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General NPI Number Information
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NPI Number | 1952583015
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Entity Type | Organization
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Legal Business Name | EAGLE LAKE CHIROPRACTIC, LLC
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Dates
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Enumeration Date | 11/30/2007
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Last Update Date | 11/30/2007
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Provider Practice Location Address
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Address Line | 12844 US HIGHWAY 431 STE B
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City | GUNTERSVILLE
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State | AL
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Zip | 35976-9312
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Country | US
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Telephone | 256-582-4330
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Fax |
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Provider Business Mailing Address
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Address Line | 12844 US HIGHWAY 431 STE B
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City | GUNTERSVILLE
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State | AL
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Zip | 35976-9312
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Country | US
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Telephone | 256-582-4330
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTIC PHYSICIAN
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Name | DR. CARRIE SOUTHERLAND
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Credential | D.C.
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Telephone | 256-582-4330
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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 | 2029
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License Number State | AL
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