Healthcare Provider Details

I. General information

NPI: 1912907296
Provider Name (Legal Business Name): DOUGLAS A. YARASCHUK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24801 5 MILE RD STE 22
REDFORD MI
48239-3654
US

IV. Provider business mailing address

24801 5 MILE RD STE 22
REDFORD MI
48239-3654
US

V. Phone/Fax

Practice location:
  • Phone: 313-387-8122
  • Fax: 313-387-8123
Mailing address:
  • Phone: 313-387-8122
  • Fax: 313-387-8123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301004938
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: