Provider Demographics
NPI:1144504010
Name:LAKE MICHIGAN CHIROPRACTIC, PLLC
Entity type:Organization
Organization Name:LAKE MICHIGAN CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:KRAIG
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:KIRKDORFER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-408-8736
Mailing Address - Street 1:4082 RED ARROW HWY.
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9431
Mailing Address - Country:US
Mailing Address - Phone:269-408-8736
Mailing Address - Fax:269-408-8790
Practice Address - Street 1:4082 RED ARROW HWY.
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9431
Practice Address - Country:US
Practice Address - Phone:269-408-8736
Practice Address - Fax:269-408-8790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKK2301009038111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P29080Medicare UPIN