Provider Demographics
NPI:1346381597
Name:SUPERIOR FAMILY CHIROPRACTIC AND WELLNESS CENTER
Entity Type:Organization
Organization Name:SUPERIOR FAMILY CHIROPRACTIC AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:906-228-2600
Mailing Address - Street 1:1301 ODOVERO DR
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-5505
Mailing Address - Country:US
Mailing Address - Phone:906-228-2600
Mailing Address - Fax:906-228-3878
Practice Address - Street 1:1301 ODOVERO DR
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-5505
Practice Address - Country:US
Practice Address - Phone:906-228-2600
Practice Address - Fax:906-228-3878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2012-02-08
Deactivation Date:2008-05-28
Deactivation Code:
Reactivation Date:2010-06-10
Provider Licenses
StateLicense IDTaxonomies
MIM0007343111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM31090Medicare ID - Type Unspecified