=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396244513
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLOURISH FAMILY CHIROPRACTIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2018
-----------------------------------------------------
Last Update Date | 02/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 51309 MOUND RD
-----------------------------------------------------
City | SHELBY TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48316-4344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-892-3339
-----------------------------------------------------
Fax | 586-323-7903
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 51309 MOUND RD
-----------------------------------------------------
City | SHELBY TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48316-4344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-892-3339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ CHIROPRACTOR
-----------------------------------------------------
Name | DR. LISA ANN LUPO
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 810-892-3339
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301010588
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------