Provider Demographics
NPI:1023205093
Name:ORCHARD LAKE CHIROPRACTIC INC
Entity Type:Organization
Organization Name:ORCHARD LAKE CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOLBUS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-489-9700
Mailing Address - Street 1:28511 ORCHARD LAKE RD STE C
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2933
Mailing Address - Country:US
Mailing Address - Phone:248-489-9700
Mailing Address - Fax:248-489-9702
Practice Address - Street 1:28511 ORCHARD LAKE RD STE C
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2933
Practice Address - Country:US
Practice Address - Phone:248-489-9700
Practice Address - Fax:248-489-9702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008701111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P14540Medicare PIN
MIY14361Medicare UPIN