Provider Demographics
NPI:1770840910
Name:ILIFF CHIROPRACTIC
Entity Type:Organization
Organization Name:ILIFF CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ILIFF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-861-4499
Mailing Address - Street 1:2560 S CLEVELAND AVE
Mailing Address - Street 2:STE 4
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2640
Mailing Address - Country:US
Mailing Address - Phone:269-983-1800
Mailing Address - Fax:269-983-1801
Practice Address - Street 1:2560 S CLEVELAND AVE
Practice Address - Street 2:STE 4
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2640
Practice Address - Country:US
Practice Address - Phone:269-983-1800
Practice Address - Fax:269-983-1801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009262111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1770840910Medicaid
MI1770840910Medicaid