Provider Demographics
NPI:1053593269
Name:LAKES CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:LAKES CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-926-1829
Mailing Address - Street 1:45023 W PONTIAC TRL
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-1255
Mailing Address - Country:US
Mailing Address - Phone:248-926-1829
Mailing Address - Fax:248-926-1837
Practice Address - Street 1:45023 W PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-1255
Practice Address - Country:US
Practice Address - Phone:248-926-1829
Practice Address - Fax:248-926-1837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007525111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M49300Medicare PIN
MIU67423Medicare UPIN