Provider Demographics
NPI:1205883923
Name:JRADI, ALI AHMED (DC)
Entity type:Individual
Prefix:MR
First Name:ALI
Middle Name:AHMED
Last Name:JRADI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2887 KRAFFT RD
Mailing Address - Street 2:STE 1000
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060
Mailing Address - Country:US
Mailing Address - Phone:810-984-1994
Mailing Address - Fax:810-984-3266
Practice Address - Street 1:2887 KRAFFT RD
Practice Address - Street 2:STE 1000
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060
Practice Address - Country:US
Practice Address - Phone:810-984-1994
Practice Address - Fax:810-984-3266
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008995111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4776847Medicaid
V06375Medicare UPIN
MI4776847Medicaid