Provider Demographics
NPI:1427304658
Name:LAKELINE CHIROPRACTIC
Entity type:Organization
Organization Name:LAKELINE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:J
Authorized Official - Last Name:KRUGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:512-401-2008
Mailing Address - Street 1:2301 S LAKELINE BLVD
Mailing Address - Street 2:B700
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-4276
Mailing Address - Country:US
Mailing Address - Phone:512-401-2008
Mailing Address - Fax:512-401-2145
Practice Address - Street 1:2301 S LAKELINE BLVD
Practice Address - Street 2:B700
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-4276
Practice Address - Country:US
Practice Address - Phone:512-401-2008
Practice Address - Fax:512-401-2145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-25
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9080111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty