Provider Demographics
NPI:1922297548
Name:DEAN CHIROPRACTIC LIFE CENTER PC
Entity Type:Organization
Organization Name:DEAN CHIROPRACTIC LIFE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTPOPHE
Authorized Official - Middle Name:BRUNDAGE
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-543-3566
Mailing Address - Street 1:28931 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-0923
Mailing Address - Country:US
Mailing Address - Phone:248-543-3566
Mailing Address - Fax:248-543-2628
Practice Address - Street 1:28931 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-0923
Practice Address - Country:US
Practice Address - Phone:248-543-3566
Practice Address - Fax:248-543-2628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICD002756111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0P09200Medicare PIN