1720117880 NPI number — LAPEER CHIROPRACTIC CENTRE PC

Table of content: DOMINGO CP FAVALE (NPI 1801818760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720117880 NPI number — LAPEER CHIROPRACTIC CENTRE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAPEER CHIROPRACTIC CENTRE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720117880
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
498 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAPEER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48446-2427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-664-5310
Provider Business Mailing Address Fax Number:
810-664-0221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
498 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAPEER
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48446-2427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-664-5310
Provider Business Practice Location Address Fax Number:
810-664-0221
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OCHADLEUS
Authorized Official First Name:
MARK
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
CHIROPRATOR
Authorized Official Telephone Number:
810-664-5310

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2301007261 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3260193 TYPE 14 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 950D450220 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 950D450220 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CH 440004 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0980076 . This is a "HEALTH PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 10369 . This is a "GREAT LAKES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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