Provider Demographics
NPI:1215116751
Name:STORK, RICHARD PRESTON (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:PRESTON
Last Name:STORK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1549 N LEROY ST STE B
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2790
Mailing Address - Country:US
Mailing Address - Phone:810-629-2757
Mailing Address - Fax:810-629-3899
Practice Address - Street 1:1549 N LEROY ST
Practice Address - Street 2:SUITE B
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2790
Practice Address - Country:US
Practice Address - Phone:810-629-2757
Practice Address - Fax:810-629-3899
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009378111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP54170001Medicare PIN