1306901137 NPI number — WYOMING CHIROPRACTIC HEALTH CLINIC,P.C.

Table of content: (NPI 1306901137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306901137 NPI number — WYOMING CHIROPRACTIC HEALTH CLINIC,P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYOMING CHIROPRACTIC HEALTH CLINIC,P.C.
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:
1306901137
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5838 KENILWORTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEARBORN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48126-2153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-581-5786
Provider Business Mailing Address Fax Number:
313-933-2252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7601 WYOMING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48126-1638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-933-1256
Provider Business Practice Location Address Fax Number:
313-933-2252
Provider Enumeration Date:
12/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REICHOUNI
Authorized Official First Name:
HASSAN
Authorized Official Middle Name:
MOHAMAD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
313-933-1256

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2301008359 , 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: 4290043 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 17354 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5215 . This is a "CAPE HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P98795 . This is a "BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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