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General NPI Number Information
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NPI Number | 1588849368
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Entity Type | Organization
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Legal Business Name | DYNAMIC LIFE CHIROPRACTIC, LLC
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Dates
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Enumeration Date | 12/30/2007
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Last Update Date | 12/30/2007
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Provider Practice Location Address
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Address Line | 725 S ADAMS RD SUITE 198
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City | BIRMINGHAM
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State | MI
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Zip | 48009-6902
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Country | US
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Telephone | 248-885-3866
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Fax |
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Provider Business Mailing Address
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Address Line | 1513 BEAUFIELD ST
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City | FERNDALE
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State | MI
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Zip | 48220-1612
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Country | US
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Telephone | 248-885-3866
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Fax |
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | DR. DANIEL J JUDGE
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Credential | D.C.
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Telephone | 248-885-3866
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 2301009205
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License Number State | MI
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