MEDICARE: CLEMENTS CHIROPRACTIC CLINIC, INC.

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	2301007332	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0170734	OTHER	MI	TOTAL HEALTH CARE
2	950E052630	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1457431017
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEMENTS CHIROPRACTIC CLINIC, INC.

Provider Business Mailing Address
First Line	:	51060 HAYES RD
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48042-4057
Country	:	US
Telephone Number	:	586-781-4314
Fax Number	:	586-781-4452

Provider Business Practice Location Address
First Line	:	51060 HAYES RD
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48042-4057
Country	:	US
Telephone Number	:	586-781-4314
Fax Number	:	586-781-4452

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DEREK M CLEMENTS
Credential	:	D.C.
Telephone Number	:	586-781-4314

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	12/29/2010

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