Provider Demographics
NPI:1205012523
Name:DESIRA CHIROPRACTIC LIFE CENTER LLC
Entity Type:Organization
Organization Name:DESIRA CHIROPRACTIC LIFE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:DESIRA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-422-7800
Mailing Address - Street 1:33250 WARREN RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-2920
Mailing Address - Country:US
Mailing Address - Phone:734-422-7800
Mailing Address - Fax:
Practice Address - Street 1:33250 WARREN RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2920
Practice Address - Country:US
Practice Address - Phone:734-422-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005025261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4951482Medicaid
MI95OH225380OtherBCBS MICHIGAN
MI4951482Medicaid
MI0P15970Medicare PIN