Provider Demographics
NPI:1659392165
Name:GRINNELL, MABEL LORRAINE (DC)
Entity Type:Individual
Prefix:DR
First Name:MABEL
Middle Name:LORRAINE
Last Name:GRINNELL
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 1:724 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1972
Mailing Address - Country:US
Mailing Address - Phone:517-782-3345
Mailing Address - Fax:517-783-3791
Practice Address - Street 1:724 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1972
Practice Address - Country:US
Practice Address - Phone:517-782-3345
Practice Address - Fax:517-783-3791
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301003065111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI142100702Medicaid
MI95OC85027OtherBLUE CROSS BLUE SHIELD MI
MIP83971OtherBLUE CARE NETWORK MI
MI142100702Medicaid