Provider Demographics
NPI:1154577435
Name:NICHOLE C. ANDERSON DC LLC
Entity type:Organization
Organization Name:NICHOLE C. ANDERSON DC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:313-891-1800
Mailing Address - Street 1:3702 E 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-1007
Mailing Address - Country:US
Mailing Address - Phone:313-891-1800
Mailing Address - Fax:313-891-1802
Practice Address - Street 1:3702 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-1007
Practice Address - Country:US
Practice Address - Phone:313-891-1800
Practice Address - Fax:313-891-1802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008912111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4801313Medicaid
MI95-OH225940OtherBCBS
MIV07995Medicare UPIN