=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194102350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEREMY D COPPLE DC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2015
-----------------------------------------------------
Last Update Date | 08/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22615 MICHIGAN AVENUE
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-585-1517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4419 WESTPOINT
-----------------------------------------------------
City | DEARBORN HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-585-1517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF CHIROPRACTIC
-----------------------------------------------------
Name | DR. JEREMY DENNIS COPPLE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 313-585-1517
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 2301010254
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------