Provider Demographics
NPI:1053538959
Name:LAKE SUPERIOR CHIROPRACTIC OFFICE, S.C.
Entity type:Organization
Organization Name:LAKE SUPERIOR CHIROPRACTIC OFFICE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:D
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-398-6679
Mailing Address - Street 1:2121 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-3610
Mailing Address - Country:US
Mailing Address - Phone:715-398-6679
Mailing Address - Fax:715-398-6080
Practice Address - Street 1:2121 E 5TH ST
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-3610
Practice Address - Country:US
Practice Address - Phone:715-398-6679
Practice Address - Fax:715-398-6080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2460111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38986200Medicaid
WI000070440Medicare ID - Type Unspecified