=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942478847
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINTZ FAMILY CHIROPRACTIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2008
-----------------------------------------------------
Last Update Date | 02/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5600 W MAPLE RD SUITE A110
-----------------------------------------------------
City | WEST BLOOMFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48322-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-737-9494
-----------------------------------------------------
Fax | 248-865-2549
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5600 W MAPLE RD SUITE A110
-----------------------------------------------------
City | WEST BLOOMFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48322-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-737-9494
-----------------------------------------------------
Fax | 248-865-2549
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ERIC MINTZ
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 248-737-9494
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | EM007699
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------