Provider Demographics
NPI:1275101263
Name:DIAGNOSTIC CHIROPRACTIC MI PC
Entity Type:Organization
Organization Name:DIAGNOSTIC CHIROPRACTIC MI PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICEPRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SUPER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:917-449-7582
Mailing Address - Street 1:201 4TH ST S UNIT 241
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4299
Mailing Address - Country:US
Mailing Address - Phone:917-449-7582
Mailing Address - Fax:
Practice Address - Street 1:201 4TH ST S UNIT 241
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4299
Practice Address - Country:US
Practice Address - Phone:917-449-7582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty