Provider Demographics
NPI:1588849368
Name:DYNAMIC LIFE CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:DYNAMIC LIFE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:JUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-885-3866
Mailing Address - Street 1:1513 BEAUFIELD ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1612
Mailing Address - Country:US
Mailing Address - Phone:248-885-3866
Mailing Address - Fax:
Practice Address - Street 1:725 S ADAMS RD
Practice Address - Street 2:SUITE 198
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6902
Practice Address - Country:US
Practice Address - Phone:248-885-3866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-30
Last Update Date:2007-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009205111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty