=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528486909
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAPLE LAKE CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2014
-----------------------------------------------------
Last Update Date | 05/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 W MICHIGAN AVE
-----------------------------------------------------
City | PAW PAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49079-1415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-876-7814
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 W MICHIGAN AVE
-----------------------------------------------------
City | PAW PAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49079-1415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-876-7814
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRITTANY M GREGORY
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 269-876-7814
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301010027
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------