Provider Demographics
NPI:1396941662
Name:OTISVILLE CHIROPRACTIC CENTER PC
Entity type:Organization
Organization Name:OTISVILLE CHIROPRACTIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGIL
Authorized Official - Middle Name:BROWN
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:810-767-6221
Mailing Address - Street 1:3413 CORUNNA RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-3265
Mailing Address - Country:US
Mailing Address - Phone:810-767-6221
Mailing Address - Fax:810-767-4429
Practice Address - Street 1:3413 CORUNNA RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-3265
Practice Address - Country:US
Practice Address - Phone:810-767-6221
Practice Address - Fax:810-767-4429
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OTISVILLE CHIROPRACTIC CENTER PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-25
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI231002905111N00000X
MI23010002905111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950B512120OtherBLUE CROSS
MI231002905OtherSTATE LICENSE NUMBER
MI231002905OtherSTATE LICENSE NUMBER
ON64490Medicare PIN
MI0N81160Medicare ID - Type Unspecified
MIT82878Medicare UPIN