=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023205093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORCHARD LAKE CHIROPRACTIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2007
-----------------------------------------------------
Last Update Date | 10/03/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28511 ORCHARD LAKE RD STE C
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48334-2933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-489-9700
-----------------------------------------------------
Fax | 248-489-9702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28511 ORCHARD LAKE RD STE C
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48334-2933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-489-9700
-----------------------------------------------------
Fax | 248-489-9702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DAVID J KOLBUS
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 248-489-9700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301008701
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------