Healthcare Provider Details

I. General information

NPI: 1609825645
Provider Name (Legal Business Name): LORI A. DILLARD D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 10/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15300 21 MILE RD STE 3
MACOMB MI
48044
US

IV. Provider business mailing address

15300 21 MILE RD STE 3
MACOMB MI
48044-5024
US

V. Phone/Fax

Practice location:
  • Phone: 586-799-7682
  • Fax: 586-799-7827
Mailing address:
  • Phone: 586-799-7682
  • Fax: 586-799-7827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number5101014290
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: