Provider Demographics
NPI:1053597906
Name:MICHAELSEN CHIROPRACTIC CENTER, P.C.
Entity type:Organization
Organization Name:MICHAELSEN CHIROPRACTIC CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:MICHAELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:903-593-5200
Mailing Address - Street 1:645 S BROADWAY AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1676
Mailing Address - Country:US
Mailing Address - Phone:903-593-5200
Mailing Address - Fax:903-535-9412
Practice Address - Street 1:645 S BROADWAY AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1676
Practice Address - Country:US
Practice Address - Phone:903-593-5200
Practice Address - Fax:903-535-9412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF002316111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00H42EOtherBCBS
TX00H42EOtherBCBS