=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679710800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LASKE FAMILY CHIROPRACTIC, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2009
-----------------------------------------------------
Last Update Date | 09/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20720 EUREKA RD
-----------------------------------------------------
City | TAYLOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48180-5313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-283-2180
-----------------------------------------------------
Fax | 734-283-2188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20720 EUREKA RD
-----------------------------------------------------
City | TAYLOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48180-5313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-283-2180
-----------------------------------------------------
Fax | 734-283-2188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. JASON P LASKE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 734-283-2180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301008988
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------