Provider Demographics
NPI:1649277096
Name:KOUKLES, THEODORE MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:MICHAEL
Last Name:KOUKLES
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 1:35525 GARFIELD RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-5521
Mailing Address - Country:US
Mailing Address - Phone:586-477-1800
Mailing Address - Fax:586-477-1815
Practice Address - Street 1:35525 GARFIELD RD
Practice Address - Street 2:SUITE B
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48035-5521
Practice Address - Country:US
Practice Address - Phone:586-477-1800
Practice Address - Fax:586-477-1815
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301002803111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI4117002Medicare PIN
MIT33115Medicare UPIN