Provider Demographics
NPI:1588123087
Name:KAZAN NUTRITION & WELLNESS CENTER PC
Entity type:Organization
Organization Name:KAZAN NUTRITION & WELLNESS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KALLIL
Authorized Official - Middle Name:
Authorized Official - Last Name:KAZAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:313-652-1000
Mailing Address - Street 1:13700 MICHIGAN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3489
Mailing Address - Country:US
Mailing Address - Phone:313-652-1000
Mailing Address - Fax:800-451-0881
Practice Address - Street 1:13700 MICHIGAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3489
Practice Address - Country:US
Practice Address - Phone:313-652-1000
Practice Address - Fax:800-451-0881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1346254604Medicaid