Provider Demographics
NPI:1477875755
Name:DYNAMIC LIFE OF MICHIGAN, LLC
Entity Type:Organization
Organization Name:DYNAMIC LIFE OF MICHIGAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-593-0843
Mailing Address - Street 1:725 S ADAMS RD
Mailing Address - Street 2:SUITE 198
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6902
Mailing Address - Country:US
Mailing Address - Phone:248-593-0843
Mailing Address - Fax:248-593-3069
Practice Address - Street 1:33966 W 8 MILE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48335-5273
Practice Address - Country:US
Practice Address - Phone:616-813-3377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-27
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty