Healthcare Provider Details

I. General information

NPI: 1053640912
Provider Name (Legal Business Name): COUNTRYSIDE CHIROPRACTIC CENTER PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 S CLARE AVE
CLARE MI
48617-9755
US

IV. Provider business mailing address

2100 S CLARE AVE
CLARE MI
48617-9755
US

V. Phone/Fax

Practice location:
  • Phone: 989-386-2931
  • Fax: 989-386-3509
Mailing address:
  • Phone: 989-386-2931
  • Fax: 989-386-3509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301008270
License Number StateMI

VIII. Authorized Official

Name: DR. LISA M JACO
Title or Position: OWNER/PRESIDENT
Credential: D.C
Phone: 989-386-2931