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General NPI Number Information
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NPI Number | 1952683708
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Entity Type | Organization
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Legal Business Name | LAKES COUNTRY CHIROPRACTIC P.A.
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Dates
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Enumeration Date | 09/16/2011
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Last Update Date | 09/16/2011
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Provider Practice Location Address
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Address Line | 157 1ST AVE S
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City | PERHAM
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State | MN
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Zip | 56573-1701
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Country | US
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Telephone | 218-346-3560
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Fax |
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Provider Business Mailing Address
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Address Line | 10213 SHERBROOKE BEACH LN
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City | PELICAN RAPIDS
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State | MN
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Zip | 56572-9332
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Country | US
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Telephone | 414-412-6322
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | VICTORIA LYNN TATRO
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Credential | DC
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Telephone | 414-412-6322
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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 | 5473
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License Number State | MN
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