Provider Demographics
NPI:1366998874
Name:LAKESIDE SPINE AND WELLNESS INC
Entity type:Organization
Organization Name:LAKESIDE SPINE AND WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:M
Authorized Official - Last Name:KIPER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-828-9506
Mailing Address - Street 1:PO BOX 180021
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-0509
Mailing Address - Country:US
Mailing Address - Phone:773-767-3822
Mailing Address - Fax:773-337-9106
Practice Address - Street 1:1828 W WILSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5204
Practice Address - Country:US
Practice Address - Phone:773-828-9506
Practice Address - Fax:773-439-5168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038013006111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty