=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962931709
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEMETRA MYDLO DC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2017
-----------------------------------------------------
Last Update Date | 06/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10990 CHICAGO DR
-----------------------------------------------------
City | ZEELAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49464-8100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-546-3500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13745 CARMELLA LN APT F
-----------------------------------------------------
City | HOLLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49424-8483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-484-9666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301010567
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------