Provider Demographics
NPI:1851577274
Name:WHITE LAKE CHIROPRACTIC D O P C
Entity Type:Organization
Organization Name:WHITE LAKE CHIROPRACTIC D O P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-698-6920
Mailing Address - Street 1:6929 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1679
Mailing Address - Country:US
Mailing Address - Phone:248-698-6920
Mailing Address - Fax:248-698-6923
Practice Address - Street 1:6929 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1679
Practice Address - Country:US
Practice Address - Phone:248-698-6920
Practice Address - Fax:248-698-6923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDM006064111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1103833049Medicaid
MI950F35490OtherBCBSM
MI95OF36930OtherBCBSM
MI95OF36930OtherBCBSM
MI1103833049Medicaid