Provider Demographics
NPI:1285737304
Name:LAKE COUNTY CHIROPRACTIC INC
Entity type:Organization
Organization Name:LAKE COUNTY CHIROPRACTIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:440-352-3500
Mailing Address - Street 1:1501 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE TWP
Mailing Address - State:OH
Mailing Address - Zip Code:44077-1702
Mailing Address - Country:US
Mailing Address - Phone:440-352-3500
Mailing Address - Fax:440-352-3512
Practice Address - Street 1:1501 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:PAINESVILLE TWP
Practice Address - State:OH
Practice Address - Zip Code:44077-1702
Practice Address - Country:US
Practice Address - Phone:440-352-3500
Practice Address - Fax:440-352-3512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1153111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH281689990002OtherMEDICAL MUTUAL
OH23797Medicaid
OH000000179338OtherANTHEM
OH23797Medicaid
OH23797Medicaid
OH000000179338OtherANTHEM