Provider Demographics
NPI:1568682201
Name:LIETZ, CHARLES MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MICHAEL
Last Name:LIETZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3584 FAIRLANES AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1583
Mailing Address - Country:US
Mailing Address - Phone:616-530-3333
Mailing Address - Fax:616-530-8320
Practice Address - Street 1:3584 FAIRLANES AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1583
Practice Address - Country:US
Practice Address - Phone:616-530-3333
Practice Address - Fax:616-530-8320
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL761039111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor