Provider Demographics
NPI:1205001807
Name:JEFFREY E. FANTICH, DC, PLC
Entity Type:Organization
Organization Name:JEFFREY E. FANTICH, DC, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:FANTICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-737-8066
Mailing Address - Street 1:6022 W MAPLE RD
Mailing Address - Street 2:SUITE 405
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-4408
Mailing Address - Country:US
Mailing Address - Phone:248-737-8066
Mailing Address - Fax:248-737-9093
Practice Address - Street 1:6022 W MAPLE RD
Practice Address - Street 2:SUITE 405
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-4408
Practice Address - Country:US
Practice Address - Phone:248-737-8066
Practice Address - Fax:248-737-9093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006930111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F35177OtherBLUE CROSS
MIU25870Medicare UPIN
MI0F35177Medicare PIN