Provider Demographics
NPI:1457399040
Name:KEVIN M KARADEEMA DC PC
Entity Type:Organization
Organization Name:KEVIN M KARADEEMA DC PC
Other - Org Name:RENAISSANCE CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KARADEEMA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:313-295-7760
Mailing Address - Street 1:22908 WICK RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3589
Mailing Address - Country:US
Mailing Address - Phone:313-295-7760
Mailing Address - Fax:
Practice Address - Street 1:22908 WICK RD
Practice Address - Street 2:SUITE B
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3589
Practice Address - Country:US
Practice Address - Phone:313-295-7760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKK005272111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIKK005272OtherLICENSE NUMBER
MI2736548Medicaid
MIU35737Medicare UPIN
MIOH25311Medicare ID - Type Unspecified