Provider Demographics
NPI:1629233150
Name:GRASS LAKE CHIROPRACTIC CENTER, PLLC
Entity Type:Organization
Organization Name:GRASS LAKE CHIROPRACTIC CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.C
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:MIKEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:517-522-8315
Mailing Address - Street 1:PO BOX 141
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-0141
Mailing Address - Country:US
Mailing Address - Phone:517-522-8315
Mailing Address - Fax:517-522-5493
Practice Address - Street 1:125 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRASS LAKE
Practice Address - State:MI
Practice Address - Zip Code:49240-9188
Practice Address - Country:US
Practice Address - Phone:517-522-8315
Practice Address - Fax:517-522-5493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009352111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950C812990OtherBLUE CROSS BLUE SHIELD
MI950C812990OtherBLUE CROSS BLUE SHIELD