Provider Demographics
NPI:1508191305
Name:MCLEOD SHELBY CHIROPRACTIC PC
Entity Type:Organization
Organization Name:MCLEOD SHELBY CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:586-992-8888
Mailing Address - Street 1:53505 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-1861
Mailing Address - Country:US
Mailing Address - Phone:586-992-8888
Mailing Address - Fax:586-992-8889
Practice Address - Street 1:53505 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-1861
Practice Address - Country:US
Practice Address - Phone:586-992-8888
Practice Address - Fax:586-992-8889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-12
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005579111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950E006390OtherBCBSM
MI950E006390OtherBCBSM