MEDICARE: MICHIGAN INTEGRATIVE WELLNESS PLLC

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	2301009967	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1043560220	OTHER	MI	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1750736203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHIGAN INTEGRATIVE WELLNESS PLLC

Provider Business Mailing Address
First Line	:	15830 FORT ST STE 3
Second Line	:
City	:	SOUTHGATE
State	:	MI
Zip	:	48195-1348
Country	:	US
Telephone Number	:	734-413-7111
Fax Number	:

Provider Business Practice Location Address
First Line	:	15830 FORT ST STE 3
Second Line	:
City	:	SOUTHGATE
State	:	MI
Zip	:	48195-1348
Country	:	US
Telephone Number	:	734-413-7111
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER
Name	:	ABDULDAYEM AHMED
Credential	:	D.C.
Telephone Number	:	734-413-7111

Provider Enumeration Date	:	05/03/2016
Last Update Date	:	08/03/2016

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