1508959438 NPI number — SPINE & SPORT CHIROPRACTIC CENTER INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508959438 NPI number — SPINE & SPORT CHIROPRACTIC CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPINE & SPORT CHIROPRACTIC CENTER INC
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:
1508959438
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 WEST SQUARE LAKE RD
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
BLOOMFIELD HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-451-1609
Provider Business Mailing Address Fax Number:
248-451-1652

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 WEST SQUARE LK RD
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
BLOOMFIELD HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-451-1609
Provider Business Practice Location Address Fax Number:
248-451-1652
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEWIS
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-451-1609

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CL007671 , 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)





Copyright © 2007-2025 www.npivalidator.com