Provider Demographics
NPI:1134386568
Name:CONANT CHIROPRACTIC CLINIC PC
Entity type:Organization
Organization Name:CONANT CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:CONANT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-241-1191
Mailing Address - Street 1:15364 S TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-4070
Mailing Address - Country:US
Mailing Address - Phone:734-241-1191
Mailing Address - Fax:734-241-1191
Practice Address - Street 1:15364 S TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-4070
Practice Address - Country:US
Practice Address - Phone:734-241-1191
Practice Address - Fax:734-241-1191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301002704111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4716544Medicaid
MI4716544Medicaid