MEDICARE: NORTHLAKE CHIROPRACTIC PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	3690	NC

General Provider Information

NPI Number	:	1174793780
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHLAKE CHIROPRACTIC PC

Provider Business Mailing Address
First Line	:	9325 CENTER LAKE DR STE 150
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-0785
Country	:	US
Telephone Number	:	704-494-4250
Fax Number	:	704-494-4256

Provider Business Practice Location Address
First Line	:	9325 CENTER LAKE DR STE 150
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-0785
Country	:	US
Telephone Number	:	704-494-4250
Fax Number	:	704-494-4256

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. LESLIE JEANNETTE MACKLIN
Credential	:	DC
Telephone Number	:	704-494-4250

Provider Enumeration Date	:	03/11/2008
Last Update Date	:	08/16/2011

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