Provider Demographics
NPI:1629046610
Name:JUNGBLUT CHIROPRACTIC CLINIC, P.C.
Entity Type:Organization
Organization Name:JUNGBLUT CHIROPRACTIC CLINIC, P.C.
Other - Org Name:SOUTHSHORE WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:JUNGBLUT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-396-7714
Mailing Address - Street 1:549 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3962
Mailing Address - Country:US
Mailing Address - Phone:616-396-7714
Mailing Address - Fax:616-396-2967
Practice Address - Street 1:549 W 18TH ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3962
Practice Address - Country:US
Practice Address - Phone:616-396-7714
Practice Address - Fax:616-396-2967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G05018Medicare ID - Type Unspecified