Provider Demographics
NPI:1528114592
Name:VAN DYKE SPINAL REHABILITATION
Entity type:Organization
Organization Name:VAN DYKE SPINAL REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR (OWNER)
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MEERON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:586-754-4690
Mailing Address - Street 1:PO BOX 381008
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-0075
Mailing Address - Country:US
Mailing Address - Phone:586-754-4690
Mailing Address - Fax:586-754-4680
Practice Address - Street 1:22860 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-2347
Practice Address - Country:US
Practice Address - Phone:586-754-4690
Practice Address - Fax:586-754-4680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005397111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950E017740OtherBCBS PROVIDER NUMBER
MI0P26620Medicare ID - Type Unspecified
MI950E017740OtherBCBS PROVIDER NUMBER