Provider Demographics
NPI:1902918519
Name:LAKE, ANDREW EDGAR (DC)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:EDGAR
Last Name:LAKE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1745
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81122-1745
Mailing Address - Country:US
Mailing Address - Phone:970-884-1072
Mailing Address - Fax:970-884-1074
Practice Address - Street 1:40031 US HIGHWAY 160
Practice Address - Street 2:SUITE C
Practice Address - City:BAYFIELD
Practice Address - State:CO
Practice Address - Zip Code:81122-8746
Practice Address - Country:US
Practice Address - Phone:970-884-1072
Practice Address - Fax:970-884-1074
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5818111N00000X
NM1657111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor