Provider Demographics
NPI:1023575586
Name:MOSURAK CHIROPRACTIC & WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:MOSURAK CHIROPRACTIC & WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSURAK
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:810-459-9144
Mailing Address - Street 1:4275 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6201 CHICAGO RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-4755
Practice Address - Country:US
Practice Address - Phone:586-264-3621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1649669425OtherTYPE 1 NPI
MI2301010264OtherSTATE LICENSE NUMBER