Provider Demographics
NPI:1649669425
Name:MOSURAK, LAWRENCE III (DC)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:
Last Name:MOSURAK
Suffix:III
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 1:6201 CHICAGO ROAD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092
Mailing Address - Country:US
Mailing Address - Phone:586-264-3621
Mailing Address - Fax:586-264-3686
Practice Address - Street 1:6201 CHICAGO ROAD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092
Practice Address - Country:US
Practice Address - Phone:586-264-3621
Practice Address - Fax:586-264-3686
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010264111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2301010264OtherSTATE LICENSE NUMBER