1124270368 NPI number — INLINE SPINES CHIROPRACTIC

Table of content: (NPI 1124270368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124270368 NPI number — INLINE SPINES CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INLINE SPINES CHIROPRACTIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WOODBECK FAMILY CHIROPRACTIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124270368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
02/04/2009
NPI Reactivation Date:
02/19/2009

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
128 W WALLED LAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALLED LAKE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48390-3455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-926-1829
Provider Business Mailing Address Fax Number:
248-926-1837

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128 W WALLED LAKE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLED LAKE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48390-3455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-926-1829
Provider Business Practice Location Address Fax Number:
248-926-1837
Provider Enumeration Date:
10/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WOODBECK
Authorized Official First Name:
ADAM
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-926-1829

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2301009136 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: BCBS PROVIDER ID . This is a "950F375750" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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