Provider Demographics
NPI:1073812293
Name:SOUTH LYON CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:SOUTH LYON CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:PENN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-306-2454
Mailing Address - Street 1:7838 5 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-9448
Mailing Address - Country:US
Mailing Address - Phone:734-306-2454
Mailing Address - Fax:
Practice Address - Street 1:327 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-4002
Practice Address - Country:US
Practice Address - Phone:734-306-2454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-28
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009723111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty