Basic Information
| Provider Information | |||||||||
| NPI: | 1114045721 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OKEMOS FAMILY CHIROPRACTIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2199 JOLLY RD | ||||||||
| Address2: | 140 | ||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488643968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173811880 | ||||||||
| FaxNumber: | 5173811990 | ||||||||
| Practice Location | |||||||||
| Address1: | 2199 JOLLY RD STE 140 | ||||||||
| Address2: | |||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488643968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173811880 | ||||||||
| FaxNumber: | 5173811990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 05/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | PERRAULT | ||||||||
| AuthorizedOfficialFirstName: | KIRBY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5173811880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 0N56140 | 01 | MI | PTAN | OTHER |