Provider Demographics
NPI:1407894843
Name:CAUDELL, GLENN A (DC)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:A
Last Name:CAUDELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23452 HILL ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-2381
Mailing Address - Country:US
Mailing Address - Phone:313-562-5742
Mailing Address - Fax:
Practice Address - Street 1:5928 N TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-3221
Practice Address - Country:US
Practice Address - Phone:313-563-0530
Practice Address - Fax:313-563-1430
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005226111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950H25164OtherBC
MIT33711Medicare UPIN
MI0H25164Medicare ID - Type Unspecified