Healthcare Provider Details

I. General information

NPI: 1295751873
Provider Name (Legal Business Name): O DELL CHIROPRACTIC CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1183 PONTIAC TRAIL
WALLED LAKE MI
48390
US

IV. Provider business mailing address

1183 PONTIAC TRAIL
WALLED LAKE MI
48390
US

V. Phone/Fax

Practice location:
  • Phone: 248-624-6111
  • Fax: 248-624-6129
Mailing address:
  • Phone: 248-624-6111
  • Fax: 248-624-6129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301007934
License Number StateMI

VIII. Authorized Official

Name: MRS. DEBORAH L O DELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 248-624-6111