Provider Demographics
NPI:1073788238
Name:NORTHWEST CHIROPRACTIC LIFE CENTER PC
Entity Type:Organization
Organization Name:NORTHWEST CHIROPRACTIC LIFE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:SJ
Authorized Official - Last Name:MURKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:517-784-9123
Mailing Address - Street 1:645 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-2024
Mailing Address - Country:US
Mailing Address - Phone:517-784-9123
Mailing Address - Fax:517-784-9150
Practice Address - Street 1:645 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2024
Practice Address - Country:US
Practice Address - Phone:517-784-9123
Practice Address - Fax:517-784-9150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301002595111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1057984-11Medicaid
MIT82909Medicare UPIN
MI0C850180-7952Medicare PIN