Provider Demographics
NPI:1164690806
Name:RICHARD P. STORK D.C. PLLC
Entity Type:Organization
Organization Name:RICHARD P. STORK D.C. PLLC
Other - Org Name:FENTON FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:STORK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:810-629-2757
Mailing Address - Street 1:1549 N LEROY ST
Mailing Address - Street 2:STE. B
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2790
Mailing Address - Country:US
Mailing Address - Phone:810-629-2757
Mailing Address - Fax:810-629-3899
Practice Address - Street 1:1549 N LEROY ST
Practice Address - Street 2:STE. B
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2790
Practice Address - Country:US
Practice Address - Phone:810-629-2757
Practice Address - Fax:810-629-3899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009378111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P54170Medicare PIN