Provider Demographics
NPI:1962679670
Name:SOUTH HAVEN CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:SOUTH HAVEN CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AHAD
Authorized Official - Middle Name:E
Authorized Official - Last Name:LOTFI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-639-7200
Mailing Address - Street 1:PO BOX 621
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49057-0621
Mailing Address - Country:US
Mailing Address - Phone:269-621-3800
Mailing Address - Fax:269-621-2556
Practice Address - Street 1:1210 PHOENIX ST
Practice Address - Street 2:SUITE 10
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-7913
Practice Address - Country:US
Practice Address - Phone:269-639-7200
Practice Address - Fax:269-621-2556
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AHAD E. LOTFI, DC., PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006100111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3427986Medicaid
MI3427986Medicaid
MIP37460001Medicare PIN