1356502249 NPI number — CHIROPRACTIC WELLNESS CENTER OF CARO PLLC

Table of content: (NPI 1356502249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356502249 NPI number — CHIROPRACTIC WELLNESS CENTER OF CARO PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIROPRACTIC WELLNESS CENTER OF CARO PLLC
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:
Provider Other Organization Name Type Code:
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:
1356502249
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
10/21/2008
NPI Reactivation Date:
01/03/2017

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
758 N STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48723-1546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-672-4141
Provider Business Mailing Address Fax Number:
989-672-4040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
758 N STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48723-1546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-672-4141
Provider Business Practice Location Address Fax Number:
989-672-4040
Provider Enumeration Date:
06/23/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GABRIEL
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
989-672-4141

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2301007693 , 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: 0G950090 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 108119 . This is a "GREAT LAKES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 099-1528 . This is a "HEALTHPLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".