Healthcare Provider Details

I. General information

NPI: 1740347103
Provider Name (Legal Business Name): CAUDELL CHIROPRACTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5928 N TELEGRAPH RD
DEARBORN HEIGHTS MI
48127-3221
US

IV. Provider business mailing address

5928 N TELEGRAPH RD
DEARBORN HEIGHTS MI
48127-3221
US

V. Phone/Fax

Practice location:
  • Phone: 313-563-0530
  • Fax: 313-563-1430
Mailing address:
  • Phone: 313-563-0530
  • Fax: 313-563-1430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301005226
License Number StateMI

VIII. Authorized Official

Name: DR. GLENN A CAUDELL
Title or Position: OWNER
Credential: DC
Phone: 313-563-0530