=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386233864
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLIE P GAUTHIER DC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2021
-----------------------------------------------------
Last Update Date | 01/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11837 MERRIMAN RD
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48150-1924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-421-0101
-----------------------------------------------------
Fax | 734-421-4895
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7246 GARVIN
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48329-2828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-212-6916
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301011025
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------