Provider Demographics
NPI:1215258546
Name:LAKELAND SPINAL HEALTH PC
Entity type:Organization
Organization Name:LAKELAND SPINAL HEALTH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:D
Authorized Official - Last Name:KOONTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:574-834-7855
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:NORTH WEBSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46555-0579
Mailing Address - Country:US
Mailing Address - Phone:574-834-7855
Mailing Address - Fax:574-834-7935
Practice Address - Street 1:118 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH WEBSTER
Practice Address - State:IN
Practice Address - Zip Code:46555
Practice Address - Country:US
Practice Address - Phone:574-834-7855
Practice Address - Fax:574-834-7935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001901A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN189750Medicare PIN
U71212Medicare UPIN