Provider Demographics
NPI:1326007956
Name:LISA A MANZ DULAC MD & ASSOCIATES PC
Entity type:Organization
Organization Name:LISA A MANZ DULAC MD & ASSOCIATES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANZ-DULAC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-884-3380
Mailing Address - Street 1:20030 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2323
Mailing Address - Country:US
Mailing Address - Phone:313-884-3380
Mailing Address - Fax:313-884-9756
Practice Address - Street 1:20030 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2323
Practice Address - Country:US
Practice Address - Phone:313-884-3380
Practice Address - Fax:313-884-9756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23D0916007OtherCLIA NUMBER
MI070H24887OtherBCBS OF MI GROUP NUMBER
MI23D0916007OtherCLIA NUMBER