Provider Demographics
NPI:1912374281
Name:SIPASEUTH, SIPHAY
Entity Type:Individual
Prefix:
First Name:SIPHAY
Middle Name:
Last Name:SIPASEUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46070 LAKE VILLA DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-3170
Mailing Address - Country:US
Mailing Address - Phone:586-298-4223
Mailing Address - Fax:
Practice Address - Street 1:46070 LAKE VILLA DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-3170
Practice Address - Country:US
Practice Address - Phone:586-298-4223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIS123766016851111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0100XChiropractic ProvidersChiropractorOccupational Health