Provider Demographics
NPI:1992072771
Name:PRENTICE FAMILY CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:PRENTICE FAMILY CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:PRENTICE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:419-621-7555
Mailing Address - Street 1:1723 COLUMBUS AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-3546
Mailing Address - Country:US
Mailing Address - Phone:419-621-7555
Mailing Address - Fax:419-621-5597
Practice Address - Street 1:1723 COLUMBUS AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-3546
Practice Address - Country:US
Practice Address - Phone:419-621-7555
Practice Address - Fax:419-621-5597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2262111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0229176Medicaid
OHPR0798941Medicare PIN
OH0229176Medicaid