Provider Demographics
NPI:1376892323
Name:WELLSPINE PC
Entity Type:Organization
Organization Name:WELLSPINE PC
Other - Org Name:WELLSPINE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT WELLSPINE PC
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTHRIE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:586-731-1188
Mailing Address - Street 1:8187 RHODE DR STE A
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-3279
Mailing Address - Country:US
Mailing Address - Phone:586-731-1188
Mailing Address - Fax:586-731-1184
Practice Address - Street 1:8187 RHODE DR STE A
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48317-3279
Practice Address - Country:US
Practice Address - Phone:586-731-1188
Practice Address - Fax:586-731-1184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009697111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH70204OtherBCBS PROVIDER ID
12153410OtherCAQH
1285942136OtherINDIVIDUAL NPI
OH70204OtherBCBS PROVIDER ID