Provider Demographics
NPI:1306901137
Name:WYOMING CHIROPRACTIC HEALTH CLINIC,P.C.
Entity type:Organization
Organization Name:WYOMING CHIROPRACTIC HEALTH CLINIC,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HASSAN
Authorized Official - Middle Name:MOHAMAD
Authorized Official - Last Name:REICHOUNI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:313-933-1256
Mailing Address - Street 1:5838 KENILWORTH ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2153
Mailing Address - Country:US
Mailing Address - Phone:313-581-5786
Mailing Address - Fax:313-933-2252
Practice Address - Street 1:7601 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1638
Practice Address - Country:US
Practice Address - Phone:313-933-1256
Practice Address - Fax:313-933-2252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008359111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4290043Medicaid
MI17354OtherGREAT LAKES HEALTH PLAN
MI5215OtherCAPE HEALTH PLAN
MIP98795OtherBCN
MI5215OtherCAPE HEALTH PLAN
MI17354OtherGREAT LAKES HEALTH PLAN