Provider Demographics
NPI:1750428058
Name:LUPO CHIROPRACTIC LIFE CENTER, P.C.
Entity type:Organization
Organization Name:LUPO CHIROPRACTIC LIFE CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:LUPO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:586-772-5876
Mailing Address - Street 1:27850 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4803
Mailing Address - Country:US
Mailing Address - Phone:586-772-5876
Mailing Address - Fax:586-772-1122
Practice Address - Street 1:27850 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4803
Practice Address - Country:US
Practice Address - Phone:586-772-5876
Practice Address - Fax:586-772-1122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225700000X, 225100000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950E001220OtherBCBS MI
MI=========OtherFEDERAL TAX ID
0N23370Medicare PIN