=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679749105
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GILL CHIROPRACTIC CENTER INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2008
-----------------------------------------------------
Last Update Date | 09/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3179 W 12 MILE RD
-----------------------------------------------------
City | BERKLEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48072-1339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-586-9167
-----------------------------------------------------
Fax | 810-225-4630
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3179 W 12 MILE RD
-----------------------------------------------------
City | BERKLEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48072-1339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-586-9167
-----------------------------------------------------
Fax | 810-225-4630
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CRAIG ALLAN GILL
-----------------------------------------------------
Credential | B.S., D.C.
-----------------------------------------------------
Telephone | 248-586-9167
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------