Provider Demographics
NPI:1871777490
Name:BELLER CHIROPRACTIC LIFE CENTER, INC
Entity type:Organization
Organization Name:BELLER CHIROPRACTIC LIFE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-282-8484
Mailing Address - Street 1:13301 REECK COURT
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-3054
Mailing Address - Country:US
Mailing Address - Phone:734-282-8484
Mailing Address - Fax:734-282-7295
Practice Address - Street 1:13301 REECK COURT
Practice Address - Street 2:SUITE 1A
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-3054
Practice Address - Country:US
Practice Address - Phone:734-282-8484
Practice Address - Fax:734-282-7295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005813111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3151958Medicaid
MI950H25342OtherBLUE CROSS BLUE SHIELD
MI0M05160Medicare PIN