Provider Demographics
NPI:1518175355
Name:GENTNER WELLNESS CLINIC PC
Entity Type:Organization
Organization Name:GENTNER WELLNESS CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:GENTNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:231-775-6381
Mailing Address - Street 1:3170 W 13TH ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-8557
Mailing Address - Country:US
Mailing Address - Phone:231-775-6381
Mailing Address - Fax:
Practice Address - Street 1:3170 W 13TH ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-8557
Practice Address - Country:US
Practice Address - Phone:231-775-6381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2098631Medicaid
MION80160Medicare ID - Type Unspecified