Provider Demographics
NPI:1144337106
Name:LIVONIA BACK & NECK PAIN CLINIC
Entity type:Organization
Organization Name:LIVONIA BACK & NECK PAIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRACE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-591-0404
Mailing Address - Street 1:36016 5 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1918
Mailing Address - Country:US
Mailing Address - Phone:734-591-0404
Mailing Address - Fax:734-591-1534
Practice Address - Street 1:36016 5 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1918
Practice Address - Country:US
Practice Address - Phone:734-591-0404
Practice Address - Fax:734-591-1534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIT97310111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJB003044OtherLICENSE NUMBER
MIT97310Medicare UPIN
MI0H25027Medicare ID - Type UnspecifiedMEDICARE PROVIDER #