Provider Demographics
NPI:1154593937
Name:LAKESIDE SPINE AND WELLNESS LLC
Entity type:Organization
Organization Name:LAKESIDE SPINE AND WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:WINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:206-852-7960
Mailing Address - Street 1:2524 CAMAS AVE NE
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-2226
Mailing Address - Country:US
Mailing Address - Phone:206-852-7960
Mailing Address - Fax:
Practice Address - Street 1:1800 NE 44TH ST STE 223
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-9035
Practice Address - Country:US
Practice Address - Phone:206-852-7960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1629035571OtherNPI
1972566529OtherNPI
1386812469OtherNPI
1386812469OtherNPI
WAGAB08607Medicare UPIN
GAB08608Medicare PIN