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General NPI Number Information
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NPI Number | 1811140858
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Entity Type | Organization
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Legal Business Name | CLYDE PARK CHIROPRACTIC, P.C.
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Dates
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Enumeration Date | 11/03/2008
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Last Update Date | 11/03/2008
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Provider Practice Location Address
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Address Line | 4315 CLYDE PARK AVE SW
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City | WYOMING
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State | MI
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Zip | 49509-4101
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Country | US
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Telephone | 616-532-4500
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Fax | 616-532-7344
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Provider Business Mailing Address
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Address Line | 4315 CLYDE PARK AVE SW
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City | WYOMING
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State | MI
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Zip | 49509-4101
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Country | US
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Telephone | 616-532-4500
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Fax | 616-532-7344
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARY E. GLADISH
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Credential | D.C.
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Telephone | 616-532-4500
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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 | 2301008725
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License Number State | MI
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