Provider Demographics
NPI:1932151909
Name:LIFESTYLE CHIROPRACTIC PC
Entity Type:Organization
Organization Name:LIFESTYLE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LAJINESS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-847-5758
Mailing Address - Street 1:8100 LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-1661
Mailing Address - Country:US
Mailing Address - Phone:734-847-5758
Mailing Address - Fax:734-847-2358
Practice Address - Street 1:8100 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182-1661
Practice Address - Country:US
Practice Address - Phone:734-847-5758
Practice Address - Fax:734-847-2358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008290111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4710110Medicaid
MI0N67290Medicare ID - Type UnspecifiedGROUP
MI4710110Medicaid
MIN67290001Medicare ID - Type UnspecifiedINDIVIDUAL