Provider Demographics
NPI:1154839231
Name:SPINE AND WELLNESS LLC
Entity Type:Organization
Organization Name:SPINE AND WELLNESS LLC
Other - Org Name:STERLING HEIGHTS SPINE AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:586-556-1060
Mailing Address - Street 1:39880 VAN DYKE AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-4670
Mailing Address - Country:US
Mailing Address - Phone:586-745-1021
Mailing Address - Fax:
Practice Address - Street 1:39880 VAN DYKE AVE STE 201
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-4670
Practice Address - Country:US
Practice Address - Phone:586-745-1021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010613261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center