Provider Demographics
NPI:1952023822
Name:1ST CHIROPRACTIC LIFE CENTER
Entity Type:Organization
Organization Name:1ST CHIROPRACTIC LIFE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRYE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:586-817-3802
Mailing Address - Street 1:12445 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3572
Mailing Address - Country:US
Mailing Address - Phone:586-817-3802
Mailing Address - Fax:
Practice Address - Street 1:12445 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3572
Practice Address - Country:US
Practice Address - Phone:586-817-3802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty