Provider Demographics
NPI:1992879134
Name:LAKE CITY CHIROPRACTIC, LTD.
Entity type:Organization
Organization Name:LAKE CITY CHIROPRACTIC, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-345-3361
Mailing Address - Street 1:127 S HIGH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55041-1637
Mailing Address - Country:US
Mailing Address - Phone:651-345-3361
Mailing Address - Fax:651-345-4049
Practice Address - Street 1:127 S HIGH ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MN
Practice Address - Zip Code:55041-1637
Practice Address - Country:US
Practice Address - Phone:651-345-3361
Practice Address - Fax:651-345-4049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3W422111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN36065OTOtherBCBS#LEROY F. OTTO,D.C.
MN36162OTOtherBCBS#LAKE CITY CHIROPRACT
MNT39797Medicare UPIN