Provider Demographics
NPI:1669637229
Name:MIKULA CHIROPRACTIC, P.C.
Entity Type:Organization
Organization Name:MIKULA CHIROPRACTIC, P.C.
Other - Org Name:MIKULA CHIROPRACTIC CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:MIKULA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-365-0255
Mailing Address - Street 1:4056 PLAINFIELD AVE NE
Mailing Address - Street 2:SUITE E
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1630
Mailing Address - Country:US
Mailing Address - Phone:616-365-0255
Mailing Address - Fax:616-365-0975
Practice Address - Street 1:4056 PLAINFIELD AVE NE
Practice Address - Street 2:SUITE E
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1630
Practice Address - Country:US
Practice Address - Phone:616-365-0255
Practice Address - Fax:616-365-0975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007183111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D15065OtherBLUE CARE NETWORK
MI3269896Medicaid
MI4443376Medicaid
MI0D17680OtherBLUE CARE NETWORK
MI950D120100OtherBLUE CROSS/BLUE SHIELD
MI950D120110OtherBLUE CROSS/BLUE SHIELD
MI950D120110OtherBLUE CROSS/BLUE SHIELD
MI0M21360Medicare PIN