Provider Demographics
NPI:1588090732
Name:DYNAMIC CHIROPRACTIC CENTERS
Entity type:Organization
Organization Name:DYNAMIC CHIROPRACTIC CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DC/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ONDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACQUES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-299-6911
Mailing Address - Street 1:555 BARCLAY CIR
Mailing Address - Street 2:STE 140
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-4555
Mailing Address - Country:US
Mailing Address - Phone:248-299-6911
Mailing Address - Fax:248-299-6915
Practice Address - Street 1:555 BARCLAY CIR
Practice Address - Street 2:STE 140
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-4555
Practice Address - Country:US
Practice Address - Phone:248-299-6911
Practice Address - Fax:248-299-6915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2014-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008019111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty