Provider Demographics
NPI:1275702383
Name:ADVANTAGE CHIROPRACTIC PC
Entity Type:Organization
Organization Name:ADVANTAGE CHIROPRACTIC PC
Other - Org Name:DC CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:DETTWILER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-301-2225
Mailing Address - Street 1:1100 4 MILE RD NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-7397
Mailing Address - Country:US
Mailing Address - Phone:616-301-2225
Mailing Address - Fax:
Practice Address - Street 1:1100 4 MILE RD NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-7397
Practice Address - Country:US
Practice Address - Phone:616-301-2225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009340111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty