Provider Demographics
NPI:1881713238
Name:MCLEOD WATERFORD CHIROPRACTIC PC
Entity type:Organization
Organization Name:MCLEOD WATERFORD CHIROPRACTIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MCLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-674-4711
Mailing Address - Street 1:4426 W WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-4073
Mailing Address - Country:US
Mailing Address - Phone:248-674-4711
Mailing Address - Fax:248-674-4712
Practice Address - Street 1:4426 W WALTON BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-4073
Practice Address - Country:US
Practice Address - Phone:248-674-4711
Practice Address - Fax:248-674-4712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI005579111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION 20460Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
OP46020Medicare PIN