Provider Demographics
NPI:1962409771
Name:LUNDSTROM, LISA MARIE (DC)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:LUNDSTROM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 LAZELLE ST STE B
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:SD
Mailing Address - Zip Code:57785-2999
Mailing Address - Country:US
Mailing Address - Phone:605-720-6288
Mailing Address - Fax:
Practice Address - Street 1:2709 LAZELLE ST STE B
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785-2999
Practice Address - Country:US
Practice Address - Phone:605-720-6288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD905111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7600553Medicaid
SDU73384Medicare UPIN
SD7791Medicare ID - Type Unspecified