Healthcare Provider Details

I. General information

NPI: 1134421019
Provider Name (Legal Business Name): LAMBROS N KOTTALIS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2010
Last Update Date: 10/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 S MILL ST
CLIO MI
48420-2324
US

IV. Provider business mailing address

14543 BLUE HERON DR
FENTON MI
48430-3268
US

V. Phone/Fax

Practice location:
  • Phone: 810-522-3095
  • Fax:
Mailing address:
  • Phone: 810-522-3095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301009759
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: