MEDICARE: LAKE COUNTY CHIROPRACTIC INC

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	1153	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	281689990002	OTHER	OH	MEDICAL MUTUAL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	000000179338	OTHER	OH	ANTHEM

General Provider Information

NPI Number	:	1285737304
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE COUNTY CHIROPRACTIC INC

Provider Business Mailing Address
First Line	:	1501 MENTOR AVE
Second Line	:
City	:	PAINESVILLE TWP
State	:	OH
Zip	:	44077-1702
Country	:	US
Telephone Number	:	440-352-3500
Fax Number	:	440-352-3512

Provider Business Practice Location Address
First Line	:	1501 MENTOR AVE
Second Line	:
City	:	PAINESVILLE TWP
State	:	OH
Zip	:	44077-1702
Country	:	US
Telephone Number	:	440-352-3500
Fax Number	:	440-352-3512

Authorized Official
Title or Position	:	OWNER PRESIDENT
Name	:	DR. BETH ANN MOON
Credential	:	DC
Telephone Number	:	440-352-3500

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	08/22/2020

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Directions to “LAKE COUNTY CHIROPRACTIC INC ” Practice Location

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