Basic Information
| Provider Information | |||||||||
| NPI: | 1811495617 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST LAKE CHIROPRACTIC & MEDICAL CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4028 13TH ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347696773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079579995 | ||||||||
| FaxNumber: | 4079577536 | ||||||||
| Practice Location | |||||||||
| Address1: | 4028 13TH ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347696773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079579995 | ||||||||
| FaxNumber: | 4079577536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2018 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | MCNICHOLS | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4079579995 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.