Provider Demographics
NPI:1336253558
Name:WEST LAKE CHIROPRACTIC PC
Entity type:Organization
Organization Name:WEST LAKE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MELLING
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-489-1999
Mailing Address - Street 1:275 N HIGHWAY 16
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037-3000
Mailing Address - Country:US
Mailing Address - Phone:704-489-1999
Mailing Address - Fax:
Practice Address - Street 1:275 N HIGHWAY 16
Practice Address - Street 2:SUITE 102
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-3000
Practice Address - Country:US
Practice Address - Phone:704-489-1999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2447111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02820OtherBCBS GROUP #