=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760749238
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TUTAK CHIROPRACTIC CLINIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2012
-----------------------------------------------------
Last Update Date | 01/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22221 INDIAN CREEK DR
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48335-5546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-871-6870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22221 INDIAN CREEK DR
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48335-5546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-871-6870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF CHIROPRACTIC
-----------------------------------------------------
Name | DR. DEAN RICHARD TUTAK
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 586-871-6870
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301002687
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------