Provider Demographics
NPI:1316108848
Name:COMPLETE HEALTH CHIROPRACTIC, PC
Entity type:Organization
Organization Name:COMPLETE HEALTH CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:517-622-2273
Mailing Address - Street 1:820 CHARLEVOIX DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-7100
Mailing Address - Country:US
Mailing Address - Phone:517-622-2273
Mailing Address - Fax:517-622-2223
Practice Address - Street 1:820 CHARLEVOIX DR
Practice Address - Street 2:SUITE 210
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-7100
Practice Address - Country:US
Practice Address - Phone:517-622-2273
Practice Address - Fax:517-622-2223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008560111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5230756Medicaid
MI0P24870Medicare PIN