MEDICARE: DANIEL NELSON MIKEL

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	2301009352	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	950C812990	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1447413380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL NELSON MIKEL

Provider Business Mailing Address
First Line	:	PO BOX 141
Second Line	:
City	:	GRASS LAKE
State	:	MI
Zip	:	49240-0141
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 W MICHIGAN AVE
Second Line	:
City	:	GRASS LAKE
State	:	MI
Zip	:	49240-9188
Country	:	US
Telephone Number	:	517-522-8315
Fax Number	:

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

Provider Enumeration Date	:	07/09/2008
Last Update Date	:	10/20/2008

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