Provider Demographics
NPI:1336280817
Name:LIFE CYCLE FAMILY CHIROPRACTIC, PC
Entity Type:Organization
Organization Name:LIFE CYCLE FAMILY CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-439-0100
Mailing Address - Street 1:1162 DEXTER ST
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:MI
Mailing Address - Zip Code:48160-1162
Mailing Address - Country:US
Mailing Address - Phone:734-439-0100
Mailing Address - Fax:734-439-7701
Practice Address - Street 1:1162 DEXTER ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MI
Practice Address - Zip Code:48160-1162
Practice Address - Country:US
Practice Address - Phone:734-439-0100
Practice Address - Fax:734-439-7701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008349111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12317OtherMCARE
MI95-0-H1-1336-0OtherBCBS
MIOH 13360OtherBCN
MIU97397Medicare UPIN
MION 41040 003Medicare ID - Type Unspecified