Provider Demographics
NPI:1073656112
Name:ROSE CITY CHIROPRACTIC CLINIC, P.C.
Entity Type:Organization
Organization Name:ROSE CITY CHIROPRACTIC CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:PAULSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:989-685-2631
Mailing Address - Street 1:3292 NORTH M33
Mailing Address - Street 2:P O BOX 27
Mailing Address - City:ROSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48654-0027
Mailing Address - Country:US
Mailing Address - Phone:989-685-2631
Mailing Address - Fax:989-685-3839
Practice Address - Street 1:3292 NORTH M33
Practice Address - Street 2:
Practice Address - City:ROSE CITY
Practice Address - State:MI
Practice Address - Zip Code:48654-0027
Practice Address - Country:US
Practice Address - Phone:989-685-2631
Practice Address - Fax:989-685-3839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006841111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950F550270OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI0F55027Medicare ID - Type Unspecified