Provider Demographics
NPI:1568843480
Name:LUPO, LISA ANN (DC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:LUPO
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 1:43740 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1122
Mailing Address - Country:US
Mailing Address - Phone:586-949-0123
Mailing Address - Fax:586-228-9019
Practice Address - Street 1:57911 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48094-2763
Practice Address - Country:US
Practice Address - Phone:586-949-0123
Practice Address - Fax:586-228-9019
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010588111N00000X
FLCH11504111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty