MEDICARE: MCLEOD SHELBY CHIROPRACTIC PC

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	2301005579	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	950E006390	OTHER	MI	BCBSM

General Provider Information

NPI Number	:	1508191305
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCLEOD SHELBY CHIROPRACTIC PC

Provider Business Mailing Address
First Line	:	53505 VAN DYKE AVE
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48316-1861
Country	:	US
Telephone Number	:	586-992-8888
Fax Number	:	586-992-8889

Provider Business Practice Location Address
First Line	:	53505 VAN DYKE AVE
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48316-1861
Country	:	US
Telephone Number	:	586-992-8888
Fax Number	:	586-992-8889

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DOUGLAS A MCLEOD
Credential	:	DC
Telephone Number	:	586-992-8888

Provider Enumeration Date	:	10/12/2009
Last Update Date	:	12/09/2010

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