Provider Demographics
NPI:1235338864
Name:ROSS CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:ROSS CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-321-5405
Mailing Address - Street 1:208 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-1432
Mailing Address - Country:US
Mailing Address - Phone:248-321-5405
Mailing Address - Fax:810-797-3615
Practice Address - Street 1:208 N MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1432
Practice Address - Country:US
Practice Address - Phone:248-321-5405
Practice Address - Fax:810-797-3615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004832111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950E034930OtherBCBSM
MI950E034930OtherBCBSM