Provider Demographics
NPI:1811025794
Name:MAINSTREET CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:MAINSTREET CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CORRADO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:586-465-6111
Mailing Address - Street 1:96 NB GRATIOT AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2349
Mailing Address - Country:US
Mailing Address - Phone:586-465-6111
Mailing Address - Fax:586-465-6100
Practice Address - Street 1:96 NB GRATIOT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2349
Practice Address - Country:US
Practice Address - Phone:586-465-6111
Practice Address - Fax:586-465-6100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007428111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty