Provider Demographics
NPI:1538158712
Name:LAKE CHIROPRACTIC CLINIC INC
Entity type:Organization
Organization Name:LAKE CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER/SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-943-4357
Mailing Address - Street 1:32313 VINE ST
Mailing Address - Street 2:
Mailing Address - City:WILLOWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44095-3341
Mailing Address - Country:US
Mailing Address - Phone:440-943-4357
Mailing Address - Fax:440-943-5178
Practice Address - Street 1:32313 VINE ST
Practice Address - Street 2:
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095-3341
Practice Address - Country:US
Practice Address - Phone:440-943-4357
Practice Address - Fax:440-943-5178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1626111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34-19718221-00OtherOHIO BWC
OH34-19718221-00OtherOHIO BWC