Provider Demographics
NPI:1114511425
Name:ADVANCED SPORTS & SPINE MGMT
Entity Type:Organization
Organization Name:ADVANCED SPORTS & SPINE MGMT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAROUN
Authorized Official - Middle Name:
Authorized Official - Last Name:FETTEH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:313-790-3998
Mailing Address - Street 1:PO BOX 7175
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48121-7175
Mailing Address - Country:US
Mailing Address - Phone:313-790-3998
Mailing Address - Fax:
Practice Address - Street 1:23350 GREENFIELD RD STE 105
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2496
Practice Address - Country:US
Practice Address - Phone:313-790-3998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty