MEDICARE: NICOLE MARIE WILBRAHAM D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2301007696	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P115498	OTHER	MI	BLUE CARE NETWORK
2	95OEO53070	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1013996834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MARIE WILBRAHAM D.C.

Provider Business Mailing Address
First Line	:	51060 HAYES RD
Second Line	:
City	:	MACOMB TOWNSHIP
State	:	MI
Zip	:	48042-4057
Country	:	US
Telephone Number	:	586-781-4314
Fax Number	:	586-781-4452

Provider Business Practice Location Address
First Line	:	51060 HAYES RD
Second Line	:
City	:	MACOMB TOWNSHIP
State	:	MI
Zip	:	48042-4057
Country	:	US
Telephone Number	:	586-781-4314
Fax Number	:	586-781-4452

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	12/29/2010

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