MEDICARE: DR. GLENN A CAUDELL DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2301005226	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	950H25164	OTHER	MI	BC

General Provider Information

NPI Number	:	1407894843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENN A CAUDELL DC

Provider Business Mailing Address
First Line	:	23452 HILL ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-2381
Country	:	US
Telephone Number	:	313-562-5742
Fax Number	:

Provider Business Practice Location Address
First Line	:	5928 N TELEGRAPH RD
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-3221
Country	:	US
Telephone Number	:	313-563-0530
Fax Number	:	313-563-1430

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	07/08/2007

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