Provider Demographics
NPI:1386074110
Name:BENJAMIN CHIROPRACTIC & FUNCTIONAL NUTRITION CENTER, P.C.
Entity type:Organization
Organization Name:BENJAMIN CHIROPRACTIC & FUNCTIONAL NUTRITION CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:517-223-9900
Mailing Address - Street 1:POB 289
Mailing Address - Street 2:114 SOUTH SECOND STREET
Mailing Address - City:FOWLERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48836-0289
Mailing Address - Country:US
Mailing Address - Phone:517-223-9900
Mailing Address - Fax:517-223-9900
Practice Address - Street 1:114 SOUTH SECOND STREET
Practice Address - Street 2:
Practice Address - City:FOWLERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48836-0289
Practice Address - Country:US
Practice Address - Phone:517-223-9900
Practice Address - Fax:517-223-9900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005319111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2301005319OtherSTATE OF MICHIGAN CHIROPRACTIC LICENSE