Provider Demographics
NPI:1558479766
Name:LAZAR, ELLEN M (DC)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:LAZAR
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42000 6 MILE RD STE 230
Mailing Address - Street 2:SUITE 230
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-3412
Mailing Address - Country:US
Mailing Address - Phone:248-924-2413
Mailing Address - Fax:248-924-2513
Practice Address - Street 1:42000 6 MILE RD
Practice Address - Street 2:SUITE 230
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48168-4336
Practice Address - Country:US
Practice Address - Phone:248-924-2413
Practice Address - Fax:248-924-2513
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIEL00005759111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU66382Medicare UPIN
MI0N68740Medicare ID - Type Unspecified