Provider Demographics
NPI:1508280751
Name:PURE CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:PURE CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-637-5072
Mailing Address - Street 1:34730 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1440
Mailing Address - Country:US
Mailing Address - Phone:734-680-8661
Mailing Address - Fax:734-680-8661
Practice Address - Street 1:34730 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1440
Practice Address - Country:US
Practice Address - Phone:734-680-8661
Practice Address - Fax:734-680-8661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-08
Last Update Date:2014-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010101111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty