Provider Demographics
NPI:1609931948
Name:TENNISWOOD, STEPHEN SCOTT (DC)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:SCOTT
Last Name:TENNISWOOD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 PAGE AVE # 104
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49254-1026
Mailing Address - Country:US
Mailing Address - Phone:517-764-5305
Mailing Address - Fax:517-647-5417
Practice Address - Street 1:4010 PAGE AVE # 104
Practice Address - Street 2:
Practice Address - City:MICHIGAN CENTER
Practice Address - State:MI
Practice Address - Zip Code:49254
Practice Address - Country:US
Practice Address - Phone:517-764-5305
Practice Address - Fax:517-647-5417
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010392111N00000X
WI3308012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI652730Medicare UPIN
WI000070920Medicare ID - Type Unspecified