Basic Information
| Provider Information | |||||||||
| NPI: | 1194881227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACKINNON | ||||||||
| FirstName: | LAURETTE | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.C. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 13020 LIVINGSTON ROAD, SUITE 14 | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341055021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392633330 | ||||||||
| FaxNumber: | 9783749716 | ||||||||
| Practice Location | |||||||||
| Address1: | 13020 LIVINGSTON ROAD, SUITE 14 | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341055021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392633330 | ||||||||
| FaxNumber: | 9783749716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/01/2007 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | CH11727 | FL | Y | Chiropractic Providers | Chiropractor | 111N00000X | 2116 | MA | N | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | Y36564 | 01 | MA | BCBSMA INDIVIDUAL NUMBER | OTHER | Y39421 | 01 | MA | BCBSMA GROUP NUMBER | OTHER |