=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982856332
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DICKENS FAMILY CHIROPRACTIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2008
-----------------------------------------------------
Last Update Date | 02/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27690 MIDDLEBELT RD
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48334-5001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-477-5222
-----------------------------------------------------
Fax | 248-477-5312
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27690 MIDDLEBELT RD
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48334-5001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-477-5222
-----------------------------------------------------
Fax | 248-477-5312
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SOLE MEMBER
-----------------------------------------------------
Name | DR. GARY DICKENS
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 248-477-5222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301009487
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------