=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144504010
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE MICHIGAN CHIROPRACTIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2011
-----------------------------------------------------
Last Update Date | 10/10/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4082 RED ARROW HWY.
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49085-9431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-408-8736
-----------------------------------------------------
Fax | 269-408-8790
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4082 RED ARROW HWY.
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49085-9431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-408-8736
-----------------------------------------------------
Fax | 269-408-8790
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF CHIROPRACTIC
-----------------------------------------------------
Name | DR. KRAIG ALAN KIRKDORFER
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 269-408-8736
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | KK2301009038
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------