Provider Demographics
NPI:1124032040
Name:EDMORE CHIROPRACTIC CLINIC, PLLC
Entity Type:Organization
Organization Name:EDMORE CHIROPRACTIC CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:989-427-5551
Mailing Address - Street 1:215 W HOWARD CITY EDMORE RD
Mailing Address - Street 2:
Mailing Address - City:EDMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48829-9779
Mailing Address - Country:US
Mailing Address - Phone:989-427-5551
Mailing Address - Fax:989-427-3102
Practice Address - Street 1:215 W HOWARD CITY EDMORE RD
Practice Address - Street 2:
Practice Address - City:EDMORE
Practice Address - State:MI
Practice Address - Zip Code:48829-9779
Practice Address - Country:US
Practice Address - Phone:989-427-5551
Practice Address - Fax:989-427-3102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006849111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E95013OtherBLUE CROSS PROVIDER I.D.
MI0E95013OtherBLUE CROSS PROVIDER I.D.
MIU57288Medicare UPIN