Provider Demographics
NPI:1285148429
Name:COMPREHENSIVE SPINE AND SPORTS CENTER, PLLC
Entity type:Organization
Organization Name:COMPREHENSIVE SPINE AND SPORTS CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEGBENRO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:716-848-0558
Mailing Address - Street 1:16108 KINGSWAY DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-1137
Mailing Address - Country:US
Mailing Address - Phone:716-848-0558
Mailing Address - Fax:
Practice Address - Street 1:28043 HOOVER RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-4167
Practice Address - Country:US
Practice Address - Phone:716-848-0558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-27
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty