Provider Demographics
NPI:1487290011
Name:PIETILA, TED
Entity type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:PIETILA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2572 US HIGHWAY 41 W STE A
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2221
Mailing Address - Country:US
Mailing Address - Phone:906-273-1158
Mailing Address - Fax:
Practice Address - Street 1:2572 US HIGHWAY 41 W STE A
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2221
Practice Address - Country:US
Practice Address - Phone:906-273-1158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010888111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor