Provider Demographics
NPI:1033413836
Name:LIEDEL CHIROPRACTIC CLINIC, INC
Entity type:Organization
Organization Name:LIEDEL CHIROPRACTIC CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.C.
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:H
Authorized Official - Last Name:LIEDEL
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:734-783-5040
Mailing Address - Street 1:27108 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-1659
Mailing Address - Country:US
Mailing Address - Phone:734-783-5040
Mailing Address - Fax:
Practice Address - Street 1:27108 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:FLAT ROCK
Practice Address - State:MI
Practice Address - Zip Code:48134-1659
Practice Address - Country:US
Practice Address - Phone:734-783-5040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005513111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0100XChiropractic ProvidersChiropractorOccupational HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3302328Medicaid
MI0Q25033Medicare PIN
MI0Q25033Medicare UPIN