Provider Demographics
NPI:1619035490
Name:LIEDEL, RONALD HARLAN JR (DC)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:HARLAN
Last Name:LIEDEL
Suffix:JR
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 1:27108 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-1659
Mailing Address - Country:US
Mailing Address - Phone:734-783-5040
Mailing Address - Fax:734-783-5403
Practice Address - Street 1:27108 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:FLAT ROCK
Practice Address - State:MI
Practice Address - Zip Code:48134-1659
Practice Address - Country:US
Practice Address - Phone:734-783-5040
Practice Address - Fax:734-783-5403
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRL005513111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0200XChiropractic ProvidersChiropractorRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3302328Medicaid
MI3302328Medicaid