| Organization Name: | NORTHERN LAKES CHIROPRACTIC CLINIC, P.C. |
| NPI Number: | 1710156443 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | RYAN LEISY (CEO) |
| Mailing Address: | 1224 Washington Ave Suite #203 Sandpoint |
| State: | ID US |
| Postal Code: | 838645055 |
| Phone Number: | 2082651900 |
| Fax Number: | 8778349457 |
| NPI Enumeration Date: | 02/27/2008 |
| NPI Last Update Date: | 02/08/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 111N00000X |
| License Number: | CHIA-1250 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Chiropractic Providers |
| Taxonomy Classification: | Chiropractor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider qualified by a Doctor of Chiropractic (D.C.), licensed by the State and who practices chiropractic medicine -that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems. |