=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750487948
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY WELLNESS CHIROPRACTIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2006
-----------------------------------------------------
Last Update Date | 05/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1465 W WASHINGTON ST
-----------------------------------------------------
City | MARQUETTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49855-3115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-226-9355
-----------------------------------------------------
Fax | 906-226-9412
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1465 W WASHINGTON ST
-----------------------------------------------------
City | MARQUETTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49855-3115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-226-9355
-----------------------------------------------------
Fax | 906-226-9412
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. GUY JOSEPH LASICH JR.
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 906-226-9355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301007766
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------