Provider Demographics
NPI:1386784692
Name:FANTICH, JEFFREY EDWARD (DC)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:EDWARD
Last Name:FANTICH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5829 W MAPLE RD
Mailing Address - Street 2:SUITE 123
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-2294
Mailing Address - Country:US
Mailing Address - Phone:248-737-8066
Mailing Address - Fax:248-737-9093
Practice Address - Street 1:5829 W MAPLE RD
Practice Address - Street 2:SUITE 123
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2294
Practice Address - Country:US
Practice Address - Phone:248-737-8066
Practice Address - Fax:248-737-9093
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006930111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI461982008OtherTAX ID
MI0F35177OtherBC PIN
MI0F35177OtherBC PIN
MIU25870Medicare UPIN