Provider Demographics
NPI:1114187242
Name:ADRIAN S GAVIGLIO DC PC
Entity Type:Organization
Organization Name:ADRIAN S GAVIGLIO DC PC
Other - Org Name:WATERFORD LIFE CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:GAVIGLIO
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTOR OF CHIROPRACT
Authorized Official - Phone:248-681-7655
Mailing Address - Street 1:3801 ELIZABETH LK RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-3017
Mailing Address - Country:US
Mailing Address - Phone:248-681-7655
Mailing Address - Fax:248-681-4088
Practice Address - Street 1:3801 ELIZABETH LK RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-3017
Practice Address - Country:US
Practice Address - Phone:248-681-7655
Practice Address - Fax:248-681-4088
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADRIAN S GAVIGLIO DC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-12
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2098168Medicaid
MI2098168Medicaid
MIT33364Medicare UPIN