Provider Demographics
NPI:1669975678
Name:SHINING LIGHT OSTEOPATHIC CARE PLLC
Entity type:Organization
Organization Name:SHINING LIGHT OSTEOPATHIC CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-799-7682
Mailing Address - Street 1:15300 21 MILE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-5024
Mailing Address - Country:US
Mailing Address - Phone:586-799-7682
Mailing Address - Fax:586-799-7827
Practice Address - Street 1:15300 21 MILE RD STE 3
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-5024
Practice Address - Country:US
Practice Address - Phone:586-799-7682
Practice Address - Fax:586-799-7827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014290261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty