Provider Demographics
NPI:1053574855
Name:EAST LAKE CHIROPRACTIC AND INJURY CENTER INC
Entity type:Organization
Organization Name:EAST LAKE CHIROPRACTIC AND INJURY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MCNICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:407-957-9995
Mailing Address - Street 1:4028 13TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-6773
Mailing Address - Country:US
Mailing Address - Phone:407-957-9995
Mailing Address - Fax:
Practice Address - Street 1:4028 13TH ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-6773
Practice Address - Country:US
Practice Address - Phone:407-957-9995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9561111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty