Organization
COUNTRYSIDE CHIROPRACTIC CENTER PLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. LISA M JACO D.C (OWNER/PRESIDENT)
(989) 386-2931
Entity
Organization
Contact information
Practice address
2100 S CLARE AVE, CLARE, MI 48617-9755
(989) 386-2931
(989) 386-3509
Mailing address
2100 S CLARE AVE, CLARE, MI 48617-9755
(989) 386-2931
(989) 386-3509
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
Primary
2301008270
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0A850110
BLUE CROSS AND BLUE SHIELD OF MICHIGAN
MI
05
—
4282720
—
MI
Enumeration date
12/23/2009
Last updated
12/23/2009
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