Provider Demographics
NPI:1124336433
Name:COOLEY LAKE NECK AND BACK CARE CLINIC LLC
Entity type:Organization
Organization Name:COOLEY LAKE NECK AND BACK CARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:LIMBACHER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-926-4050
Mailing Address - Street 1:2171 N PONTIAC TRL
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3162
Mailing Address - Country:US
Mailing Address - Phone:248-926-4050
Mailing Address - Fax:248-926-4050
Practice Address - Street 1:2171 N PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48390-3162
Practice Address - Country:US
Practice Address - Phone:248-926-4050
Practice Address - Fax:248-926-4050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-21
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI3149001Medicare PIN