=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073788238
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST CHIROPRACTIC LIFE CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2008
-----------------------------------------------------
Last Update Date | 04/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 645 SAINT CLAIR AVE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49202-2024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-784-9123
-----------------------------------------------------
Fax | 517-784-9150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 645 SAINT CLAIR AVE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49202-2024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-784-9123
-----------------------------------------------------
Fax | 517-784-9150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KENNETH S.J. MURKOWSKI
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 517-784-9123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301002595
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------