MEDICARE: DR. CHARLES MICHAEL LIETZ 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	L761039	MI

General Provider Information

NPI Number	:	1568682201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES MICHAEL LIETZ D.C.

Provider Business Mailing Address
First Line	:	3584 FAIRLANES AVE SW
Second Line	:
City	:	GRANDVILLE
State	:	MI
Zip	:	49418-1583
Country	:	US
Telephone Number	:	616-530-3333
Fax Number	:	616-530-8320

Provider Business Practice Location Address
First Line	:	3584 FAIRLANES AVE SW
Second Line	:
City	:	GRANDVILLE
State	:	MI
Zip	:	49418-1583
Country	:	US
Telephone Number	:	616-530-3333
Fax Number	:	616-530-8320

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

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	07/08/2007

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