Provider Demographics
NPI:1992713903
Name:LAKESIDE CHIROPRACTIC PC
Entity type:Organization
Organization Name:LAKESIDE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:B
Authorized Official - Last Name:VYROSTEK
Authorized Official - Suffix:
Authorized Official - Credentials:DC CCSP
Authorized Official - Phone:814-382-1970
Mailing Address - Street 1:10633 STATE HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:16316-3225
Mailing Address - Country:US
Mailing Address - Phone:814-382-1970
Mailing Address - Fax:814-382-3619
Practice Address - Street 1:10633 STATE HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:CONNEAUT LAKE
Practice Address - State:PA
Practice Address - Zip Code:16316-3225
Practice Address - Country:US
Practice Address - Phone:814-382-1970
Practice Address - Fax:814-382-3619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA350056097OtherPALMETTO GBA
PA350056097OtherRR MEDICARE
PA060136Medicare ID - Type Unspecified