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General NPI Number Information
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NPI Number | 1811025794
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Entity Type | Organization
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Legal Business Name | MAINSTREET CHIROPRACTIC LLC
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Dates
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Enumeration Date | 03/01/2007
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Last Update Date | 09/25/2012
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Provider Practice Location Address
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Address Line | 96 NB GRATIOT AVE SUITE 100
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City | MOUNT CLEMENS
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State | MI
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Zip | 48043-2349
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Country | US
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Telephone | 586-465-6111
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Fax | 586-465-6100
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Provider Business Mailing Address
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Address Line | 96 NB GRATIOT AVE SUITE 100
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City | MOUNT CLEMENS
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State | MI
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Zip | 48043-2349
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Country | US
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Telephone | 586-465-6111
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Fax | 586-465-6100
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. STACY L CORRADO
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Credential | DC
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Telephone | 586-465-6111
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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 | 2301007428
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License Number State | MI
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