Provider Demographics
NPI:1518072776
Name:PLYMOUTH CHIROPRACTIC WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:PLYMOUTH CHIROPRACTIC WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:SISK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-459-7090
Mailing Address - Street 1:908 PENNIMAN AVE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1624
Mailing Address - Country:US
Mailing Address - Phone:734-453-7090
Mailing Address - Fax:734-453-9992
Practice Address - Street 1:908 PENNIMAN AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1624
Practice Address - Country:US
Practice Address - Phone:734-453-7090
Practice Address - Fax:734-453-9992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006903111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950H228640OtherBLUE CARE NETWORK (DR.E BCBS ID NUMBER)
MI1316980287OtherDR E NPI
MI1316980337OtherDR OMEL NPI
MI950H228250OtherBCBS OF MICHIGAN
MI1316980337OtherDR OMEL NPI
MIU93609Medicare UPIN
MIN28140011Medicare ID - Type UnspecifiedDR OMEL
MI0N53210Medicare ID - Type Unspecified